Exercise training improves activity in adolescents with congenital heart disease.

OBJECTIVES: To ascertain if motivational techniques and a structured exercise programme can increase activity in adolescents afflicted with congenital heart disease (CHD). DESIGN: Prospective randomised controlled trial. SETTING: One hundred and forty-three patients aged 12-20 years attending the tertiary centre for paediatric cardiology in Northern Ireland. MAIN OUTCOME MEASURES: Increase in exercise capacity as assessed by duration of exercise stress test, and number of minutes spent in moderate to vigorous physical activity (MVPA) per day. RESULTS: Eighty-six patients were men (60%), mean age was 15.60 ± 2.27 years. Seventy-three percent were considered to have major CHD. Seventy-two participants were randomised to the intervention group. Following intervention, duration of exercise test increased by 1 min 5 s for the intervention group (p value 0.02) along with increase in predicted VO2Max (p value 0.02). There was a significant increase in minutes of MVPA per day for the intervention group from baseline to reassessment (p value <0.001) while MVPA remained much the same for the control group. Fourteen patients met the current recommendation for more than 60 min MVPA per day at baseline. This doubled to 29 participants at reassessment. There were no adverse effects or mortalities reported. CONCLUSIONS: Exercise training is safe, feasible and beneficial in adolescents with CHD. Psychological techniques can be employed to maximise the impact of interventions. TRIAL REGISTRATION NUMBER: ISRCTN27986270.

Examination of the physical and psychosocial determinants of health behaviour in 4-5-year-old children with congenital cardiac disease.

OBJECTIVES: To assess the general health and activity levels of 4- and 5-year-old children after intervention for congenital cardiac disease. METHODS: Health behaviour outcomes were assessed in 91 children who had surgery or catheter intervention for congenital cardiac disease. The children were classified into four groups according to severity. The main parameters of classification were the presence of residual symptoms, frequency of visits to general practitioner or the Accident and Emergency Department, and ability to participate in physical activity according to a calculated "activity score". RESULTS: Children had very few residual symptoms after "corrective surgery". Those with complex congenital cardiac disease post-Fontan-type repair still had symptoms on average 18.2 days per month. Surprisingly, the complex group had fewer days "sick" from non-cardiac causes and had fewer visits to general practitioner or Accident and Emergency Departments. Regression analysis indicates that three variables had significant relevance to the general practitioner or Accident and Emergency visits: complex congenital cardiac disease, fewer visits; Townsend score - more deprivation - more visits; and maternal worry - higher maternal worry score - more visits. Regression analysis indicates that lower activity score is significantly related to complex cardiac disease and higher maternal worry score. CONCLUSIONS: The majority of this group of 4- and 5-year-old children had few residual symptoms and had good exercise tolerance. Maternal worry is a significant factor in influencing both activity levels and frequency of unscheduled health service demands - general practitioner or Accident and Emergency visits.

A controlled trial of early interventions to promote maternal adjustment and development in infants born with severe congenital heart disease.

Abstract Background Congenital heart disease can have a negative impact on both infant development and maternal adjustment. This study considered the impact of a new programme of early psychosocial interventions on such outcomes, following the birth of a child with severe congenital heart disease. Methods Seventy infants and their mothers were assigned to an intervention or control group based on order of presentation to the unit. Interventions aimed at bolstering mother-infant transactions, through psychoeducation, parent skills training and narrative therapy techniques were implemented. Results Clinically and statistically significant gains were observed at 6-month follow-up on the mental (but not the psychomotor) scale of the Bayleys-II. Positive gains were also manifested on feeding practices, maternal anxiety, worry and appraisal of their situation. Conclusions A programme of generalizable psychosocial interventions is shown to have a positive impact on the infant with severe congenital heart disease and the mother.

Determinants of neuropsychological and behavioural outcomes in early childhood survivors of congenital heart disease.

AIMS: To evaluate the relative effect of cyanosis, surgical interventions and family processes on neuropsychological and behavioural outcomes in 4-year-old survivors of serious congenital heart disease (CHD). METHODS: 90 children with a range of cyanotic and acyanotic conditions, who underwent either corrective or palliative surgery, completed a neuropsychological and behavioural evaluation. Families of participants were also profiled by evaluation of maternal mental health, worry, social support, parenting style and family functioning. RESULTS: Compromised neuropsychological outcomes were associated with a combination of cyanotic conditions and open-heart surgery, but this was not exacerbated by having a complex, palliative, status. Both cyanotic and acyanotic conditions were associated with specific sensorimotor delays, regardless of method of the correction. Only children with complex conditions and palliative interventions seemed at risk of poor behavioural outcomes; indeed, children with cyanosis with complete repair showed favourable behavioural outcomes compared with controls. Multivariate analyses highlighted the sometimes greater relevance of family processes (eg parenting style, maternal mental health and worry), rather than disease or surgical factors, in predicting especially behavioural outcomes. CONCLUSIONS: The findings (1) suggest a more complex relationship between cyanosis, surgical methods of correction, neuropsychological and behavioural outcomes than previously charted, (2) highlight that family processes may be aetiologically more important than disease and surgical factors, and (3) indicate specific targets for secondary prevention programmes for this at-risk population.

Cognitive biases and addiction: an evolution in theory and method.

An evolution in theoretical models and methodological paradigms for investigating cognitive biases in the addictions is discussed. Anomalies in traditional cognitive perspectives, and problems with the self-report methods which underpin them, are highlighted. An emergent body of cognitive research, contextualized within the principles and paradigms of cognitive neuropsychology rather than social learning theory, is presented which, it is argued, addresses these anomalies and problems. Evidence is presented that biases in the processing of addiction-related stimuli, and in the network of propositions which motivate addictive behaviours, occur at automatic, implicit and pre-conscious levels of awareness. It is suggested that methods which assess such implicit cognitive biases (e.g. Stroop, memory, priming and reaction-time paradigms) yield findings which have better predictive utility for ongoing behaviour than those biases determined by self-report methods of introspection. The potential utility of these findings for understanding "loss of control" phenomena, and the desynchrony between reported beliefs and intentions and ongoing addictive behaviours, is discussed. Applications to the practice of cognitive therapy are considered.

Psychological management of intractable seizures in an adolescent with a learning disability.

Psychological interventions aimed at seizure management are described with a 14-year-old boy with a learning disability and intractable epilepsy. Baseline records suggested that a majority of tonic seizures and 'drop attacks' were associated with going off to sleep and by environmental 'startles'. Psychological formulation implicated sudden changes in arousal levels as an underlying mechanism of action. Cognitive-behavioural countermeasures were employed to alter arousal levels and processes in different ways in different 'at-risk' situations. A multiple baseline design was used to control for non-specific effects of interventions on non-targeted seizures. Results suggested significant declines in the number of sleep onset and startle-response seizures were attained by these methods. Gains were maintained at 2-month follow-up.

A long-term follow-up of cognitive, emotional, and behavioural sequelae to Reye syndrome.

Eighteen adolescents who had survived Reye syndrome (RS) in early childhood were assessed on cognitive, emotional, and behavioural variables in a second follow-up study tracking this group. Siblings were used as controls. The entire group with RS had survived with no obvious neurological damage at the first follow-up study. Indeed, current findings suggested that long-term cognitive, emotional, and behavioural functioning was comparable to siblings in approximately half of the group with RS. However, two factors were associated with a less favourable outcome. Cognitive, emotional, and behavioural functioning were significantly poorer in the subgroup of survivors whose illness had occurred in the first year of life. In addition, loss of consciousness, although the association with poor outcome was not as noticeable, was also associated with relative deficits on some scales of cognitive ability. Many of these deficits had not been obvious at the first follow-up and the importance of neurodevelopmental factors are considered. Finally, the implications of these findings for research and interventions in RS and other such encephalopathies are discussed.

Automaticity of cognitive biases in addictive behaviours: further evidence with gamblers.

OBJECTIVES: The hypotheses that automatic, non-volitional, attentional and memory biases for addiction-related constructs exist is tested with compulsive gamblers. DESIGN: An independent groups design was employed. Processing of gambling, compared to neutral and drug-related information was examined in 15 gamblers recruited from new members of Gamblers Anonymous. Comparisons were made with the performance of their spouses (N = 15) to help distinguish addiction mechanisms from more non-specific emotional experiences with gambling, and an independent control group (N = 15), recruited from the staff and students of a university department. METHODS: A modified Stroop procedure was first employed. Automative cognitive interference was assessed relatively, by comparing colour-naming times on the gambling, drug and neutral Stroops. A subsequent word-stem completion task of implicit memory was then used to assess selective and automatic priming of the gambling constructs in memory. RESULTS: Only the gamblers showed selective and automatic interference for gambling-related constructs on the Stroop task. Spouses behaved like the control group on this task. An implicit memory bias for gambling-related words was statistically detected only in the gamblers compared to the control group, although the trend was similar in the comparison with spouses. Further evidence for the specificity of these effects was obtained in subgroup comparisons involving fruit-machine with racing gamblers. CONCLUSIONS: Results are generally consistent with an automaticity in the cognitive biases gamblers show for gambling-related information. Implications for cognitive understanding and treatments are highlighted.

Cue-exposure to alcohol-associated stimuli reduces autonomic reactivity, but not craving and anxiety, in dependent drinkers.

A controlled trial was conducted of cue-exposure with dependent drinkers in treatment. All subjects were engaged in an insight-oriented therapy programme, and responses to an alcohol-associated, compared with a neutral, stimulus were assessed at the beginning and end of treatment. Compared with a control group, which did not receive intervening cue-exposure sessions, subjects who received such interventions manifested reductions in heart rate, salivation and arousal responses to the alcohol-associated, compared with the neutral, stimulus. They did not, however, show similar reductions in subjective estimates of craving and anxiety. These results and the desynchrony in reductions in cue-reactivity across response domains are discussed in terms of their implications for cue-exposure in treatment and recent theorectical conceptualizations of the relationship between autonomic reactivity, craving and drinking behaviour.

The cue-responsivity phenomenon in dependent drinkers: 'personality' vulnerability and anxiety as intervening variables.

The cue-responsivity phenomenon to alcohol-associated stimuli in dependent drinkers was examined. In accordance with previous research, significant differences on both physiological and subjective cue-responsivity variables, between dependent and non-dependent drinkers were found. The unique contribution of this paper is two-fold. Firstly, evidence is presented which suggests that the Eysenckian personality traits of introversion and neuroticism are more predictive of cue-responsivity variance in the dependent drinkers than either severity of dependence or number of years' drinking. Secondly, within this dependent group, the relationship between cue-responsivity and 'craving' was seen to be less straightforward than traditionally thought. Specifically, it suggested that it was the extent to which autonomic cue-responsivity elicited increases in self-reported anxiety, which predicted most of the variance on the 'craving' variable. Taken together, these results raise the interesting possibility that a personality disposition akin to trait anxiety, and the degree to which cue exposure elicits state anxiety, mediated the relationship between cue-responsivity and 'craving' in dependent drinkers.

Alcohol-predictive cues enhance tolerance to and precipitate "craving" for alcohol in social drinkers.

This study attempts to show that tolerance to alcohol is in large part a "learned" response, precipitated by contextual cues predictive of the unconditional drug effect. It also aims to show that the contextual cues integral to such "environment-dependent" tolerance function to increase motivational desire to drink alcohol. Male students (N = 40), drinking on average 10-20 units of alcohol per week, were randomly assigned to one of four groups. Two groups ingested 1.2ml/kg alcohol: one (AL-EXPT) with exteroceptive contextual cues typically associated with alcohol use, and the other (AL-UNEXPT) in a context not normally associated with alcohol. A third group (placebo) believed that they were drinking alcohol but, in fact, consumed a nonalcoholic beverage in the alcohol-expected context. The fourth group drank juice in the alcohol-unexpected context. As predicted, tolerance to the deleterious effects of alcohol on cognition and motor-performance, and subjective desire to consume alcohol, were influenced by the alcohol-predictive contextual cues. A physiological index (pulse rate) also tended to confirm that these cues elicited a conditioned compensatory response to alcohol. The implications of these findings for tolerance to and motivation to drink alcohol in a nonpathological population are discussed.

Conditioned ethanol preference in rats.

The question of whether ethanol has intrinsically rewarding properties, or whether, as a discriminative stimulus, it can become a conditioned reinforcer as a function of context association was examined. Paired rats consumed more of an ethanol solution than isolated rats over a 15 day 'conditioning' phase and their ingestion rate was increased significantly over the 15 day period. Furthermore, animals exposed to the solution with a conspecific companion during this conditioning phase subsequently showed a marked preference for ethanol over water throughout a 10 day test phase (when all animals were alone) compared to those with prior experience of the solution in isolation. Both groups consumed significantly more ethanol than the controls (with no prior ethanol experience at all) during this test phase. The results suggest that the total context of initial exposure to ethanol mediate its subsequent reinforcing properties, with the prior pleasurable context of being with a conspecific companion generalizing to the ethanol stimulus for the paired group.