Experience of Self-Harm and Its Treatment in Looked-After Young People: An Interpretative Phenomenological Analysis.

We report the first Interpretative Phenomenological Analysis examination of self-harm and experience of clinical services in young people in the public care system. Qualitative interviews with 24 looked-after young people were completed. Prevalent themes were 1) Changes in care placement, 2) Feelings of anger, 3) Not wanting/feeling able to talk, 4) Developing coping techniques, 5) Clinical services: A relational mixed bag (subthemes: feeling (i) patronized, not listened to, (ii) nothing being done, (iii) comfortable/able to talk). Placement change and anger were highly salient to self-harm in this group and experiences of clinical services depended on individual relationships with clinicians. Implications include increasing compassion in therapeutic relationships, recognizing and managing emotional dysregulation, and increasing support during placement changes.

Cross-cultural measurement invariance of the Revised Child Anxiety and Depression Scale across 11 world-wide societies.

BACKGROUND: In order to compare estimates by one assessment scale across various cultures/ethnic groups, an important aspect that needs to be demonstrated is that its construct across these groups is invariant when measured using a similar and simultaneous approach (i.e., demonstrated cross-cultural measurement invariance). One of the methods for evaluating measurement invariance is testing for differential item functioning (DIF), which assesses whether different groups respond differently to particular items. The aim of this study was to evaluate the cross-cultural measurement invariance of the Revised Child Anxiety and Depression Scale (RCADS) in societies with different socioeconomic, cultural, and religious backgrounds. METHODS: The study was organised by the International Child Mental Health Study Group. Self-reported data were collected from adolescents residing in 11 countries: Brazil, Bulgaria, Croatia, Indonesia, Montenegro, Nigeria, Palestinian Territories, the Philippines, Portugal, Romania and Serbia. The multiple-indicators multiple-causes model was used to test the RCADS items for DIF across the countries. RESULTS: Ten items exhibited DIF considering all cross-country comparisons. Only one or two items were flagged with DIF in the head-to-head comparisons, while there were three to five items flagged with DIF, when one country was compared with the others. Even with all cross-culturally non-invariant items removed from nine language versions tested, the original factor model representing six anxiety and depressive symptoms subscales was not significantly violated. CONCLUSIONS: There is clear evidence that relatively small number of the RCADS items is non-invariant, especially when comparing two different cultural/ethnic groups, which indicates on its sound cross-cultural validity and suitability for cross-cultural comparisons in adolescent anxiety and depressive symptoms.

Uncovering key patterns in self-harm in adolescents: Sequence analysis using the Card Sort Task for Self-harm (CaTS).

BACKGROUND: Self-harm is a significant clinical issue in adolescence. There is little research on the interplay of key factors in the months, weeks, days and hours leading to self-harm. We developed the Card Sort Task for Self-harm (CaTS) to investigate the pattern of thoughts, feelings, events and behaviours leading to self-harm. METHODS: Forty-five young people (aged 13-21 years) with recent repeated self-harm completed the CaTS to describe their first ever/most recent self-harm episode. Lag sequential analysis determined significant transitions in factors leading to self-harm (presented in state transition diagrams). RESULTS: A significant sequential structure to the card sequences produced was observed demonstrating similarities and important differences in antecedents to first and most recent self-harm. Life-events were distal in the self-harm pathway and more heterogeneous. Of significant clinical concern was that the wish to die and hopelessness emerged as important antecedents in the most recent episode. First ever self-harm was associated with feeling better afterward, but this disappeared for the most recent episode. LIMITATIONS: Larger sample sizes are necessary to examine longer chains of sequences and differences in genders, age and type of self-harm. The sample was self-selected with 53% having experience of living in care. CONCLUSIONS: The CaTs offers a systematic approach to understanding the dynamic interplay of factors that lead to self-harm in young people. It offers a method to target key points for intervention in the self-harm pathway. Crucially the factors most proximal to self-harm (negative emotions, impulsivity and access to means) are modifiable with existing clinical interventions.

Exposure to war traumatic experiences, post-traumatic stress disorder and post-traumatic growth among nurses in Gaza.

ACCESSIBLE SUMMARY: What is known on the subject? This study builds on existing research on war-related factors that may affect health-care staff by particularly focusing on trauma exposure in both professional and everyday life, as well as on correlates of later positive psychological changes. What this paper adds to existing knowledge? It shows that one in five nursing staff working in Gaza experienced post-traumatic stress symptoms within the clinical range, 2 years after an incursion on Gaza and after being exposed to substantial trauma during this period. Participants appeared to develop a variety of post-traumatic growth responses following trauma exposure. Although nurses experienced traumatic events both as civilians and in their health-care capacity, personal exposure was strongly associated with PTSD symptoms. What are the implications for practice? Support to nursing and other health-care professionals in war situations should entail different levels, remain available well after an acute conflict, and take into consideration both personal and practice-related traumatic events. Mental health nursing practitioners can play a pivotal role in this. AIM: To establish the association between war traumatic experiences, post-traumatic stress disorder (PTSD) symptoms and post-traumatic growth among nurses in the Gaza Strip, 2 years after an incursion on Gaza, and during a period of ongoing trauma exposure. This study builds on existing evidence by considering exposure to personal and work-related traumatic events, and on factors associated with later positive psychological adaptation. METHODS: The sample consisted of 274 randomly selected nurses in Gaza who completed the Gaza Traumatic Events Checklist, PTSD Checklist, and Posttraumatic Growth Inventory. RESULTS: Of the nurses, 19.7% reported full PTSD. There was a significant relationship between traumatic events and PTSD scores; as well as between community-related traumatic events and post-traumatic growth. Participants reported a range of traumatic events, but PTSD and post-traumatic growth scores were more strongly associated with community rather than work-related traumas. DISCUSSION: Nursing professionals experienced high levels of distress 2 years following an acute period of conflict, both as civilians and in their health-care capacity. IMPLICATIONS FOR PRACTICE: There is need for different levels of support for health-care staff in war-affected areas. Mental health nursing professionals have a central role in training, counselling and support to other health-care colleagues.

The effect of aerobic exercise in the maintenance treatment of depression.

We investigated the efficacy of aerobic exercise alongside antidepressant medication as an adjuvant maintenance treatment for depression. Fifty patients in remission were randomly assigned to either medication only or medication plus exercise. Assessment of psychopathology was made at 6-weekly intervals (for 24 weeks) using the Hamilton Rating Scale for Depression. The medication-plus-exercise group showed significantly more improvement at 12 and 24 weeks than the medication-only group. This study adds to a growing evidence base that suggests aerobic exercise is worthy of further development in the treatment of depressive disorders.

Does the Strengths and Difficulties Questionnaire - self report yield invariant measurements across different nations? Data from the International Child Mental Health Study Group.

AIMS: This study evaluated the measurement invariance of the strengths and difficulties questionnaire (SDQ) self-report among adolescents from seven different nations. METHODS: Data for 2367 adolescents, aged 13-18 years, from India, Indonesia, Nigeria, Serbia, Turkey, Bulgaria and Croatia were available for a series of factor analyses. RESULTS: The five-factor model including original SDQ scales emotional symptoms, conduct problems, hyperactivity-inattention problems, peer problems and prosocial behaviour generated inadequate fit degree in all countries. A bifactor model with three factors (i.e., externalising, internalising and prosocial) and one general problem factor yielded adequate degree of fit in India, Nigeria, Turkey and Croatia. The prosocial behaviour, emotional symptoms and conduct problems factor were found to be common for all nations. However, originally proposed items loaded saliently on other factors besides the proposed ones or only some of them corresponded to proposed factors in all seven countries. CONCLUSIONS: Due to the lack of a common acceptable model across all countries, namely the same numbers of factors (i.e., dimensional invariance), it was not possible to perform the metric and scalar invariance test, what indicates that the SDQ self-report models tested lack appropriate measurement invariance across adolescents from these seven nations and it needs to be revised for cross-country comparisons.

'They're not witches. ' Young children and their parents' perceptions and experiences of Child and Adolescent Mental Health Services.

BACKGROUND: Recent initiatives have emphasized the ongoing need to include children in healthcare research, which is relevant to the development of both paediatric and mental healthcare services. Our aim was to contribute children and their parents' perceptions and experiences of Child and Adolescent Mental Health Services (CAMHS), with the objective of providing guidance for those wishing to improve inclusivity and empowerment. METHOD: We performed a thematic analysis of interview data taken from 11 children (9 boys, 2 girls, aged 8-12) and their parents (12 mothers, 2 fathers), who had recently been referred to CAMHS for mental health and educational problems. RESULTS: Three core themes emerged from the data. Fear of the unknown refers to emotional apprehension due to uncertainty of what happens in CAMHS. However children also provided useful reassurances for future service users. Therapeutic engagement refers to the importance of being listened to and building up good relationships with professionals. Finally making services acceptable was discussed in terms of issues of accessibility, session tolerances and suggestions for the development of child-centred services. CONCLUSIONS: Children were able to provide potentially useful opinions of CAMHS. In a time of limited resources it is imperative that the voices of children and their parents are acknowledged in order to improve accessibility and experiences within CAMHS.

Role of personal and family factors in alcohol and substance use among adolescents: an international study with focus on developing countries.

Most studies examining adolescent alcohol and substance use or abuse hardly include samples from developing countries. To bridge some gap, the prevalence and associated social correlates of alcohol and substance use and abuse was examined among a cohort of school-going adolescents sampled from seven developing countries. Alcohol and substance abuse was measured using the CRAFFT instrument, independent socio-demographic correlates were determined using regression models. A total of 2454 adolescents completed the study, among which 40.9% reported using either alcohol or at least one other substance during the previous 12 months. This was mostly alcohol (37.8%), followed by marijuana/hashish (8.6%) and other substances (8.1%). Among the adolescents who reported using at least one substance, 45% (18.3% of total sample) had CRAFFT scores indicative of problematic or hazardous substance use. Several personal and family factors were independently associated with use/abuse, and the modifiable nature of these factors calls for appropriate intervention strategies.

Victims of bullying in childhood and suicide attempts in adulthood.

PURPOSE: To examine whether self-reported exposure to bullying during childhood is associated with suicide attempts over the life course, and if so, what mechanisms could account for this relationship. SUBJECTS AND METHODS: A random probability sample comprising 7461 respondents was interviewed for the 2007 survey of psychiatric morbidity of adults in Great Britain. Survey respondents were asked about suicidal attempts and whether they were bullied in childhood. RESULTS: Recall of being bullied in childhood decreased with age from 25% of 16-24-year-olds to 4% among those 75 or over with few differences in the proportions between men and women. Bullying co-occurred with several victimisation experiences including sexual abuse and severe beatings and with running away from home. Even after controlling for lifetime factors known to increase the risk of suicidal behaviour, adults who reported bullying in childhood were still more than twice as likely as other adults to attempt suicide later in life. DISCUSSION: Being the victim of bullying involves the experience of suffering a defeat and humiliation that in turn could lead to entrapment, hopelessness, depression and suicidal behaviour. CONCLUSIONS: Bullying is already known to be associated with substantial distress and other negative consequences and this further evidence of a strong correlation with the risk of suicide in later life should increase further the motivation of society, services and citizens to act decisively to reduce bullying in childhood.

Mental health problems among labour children in the Gaza Strip.

BACKGROUND: There is increasing international concern over the rising number of children involved in labour, particularly in developing countries. Despite the multitude of related risk factors, and some evidence on their social needs, there has been limited research on these children's mental health. METHODS: The aim of this study was to establish the association between labour-related variables and mental health problems among 780 children in labour (aged 9-18 years, mean 15.8) in the Gaza Strip. Measures included a demographic checklist, the Strengths and Difficulties Questionnaire, the Spence Children's Anxiety Scale and the Depression Self-rating Scale for Children. RESULTS: Children came from large families (73.2% had eight or more siblings), mainly worked to increase family income, worked an average 6.8 h per day (range 1-16), and only 37.1% had regular rest. Ratings of mental health problems were predicted by different factors, i.e. total difficulties scores by poor friendship relationships and lack of health insurance; anxiety scores by selling in the streets, working to help family, low family income and lack of health insurance; and depression scores by parents' dissatisfaction with the job and longer working hours. CONCLUSIONS: Mental health problems of children in labour are likely to be associated with socio economic determinants, as well as factors related to their under age employment. Policy, legislation and preventive programmes from statutory and voluntary agencies should adopt an integrated approach in meeting their mental health needs, by enhancing protective factors such as return to school.

Attention deficit-hyperactivity symptoms among Palestinian children.

We aimed to establish the prevalence and distribution of attention deficit-hyperactivity disorder (ADHD) symptoms and other associated comorbid mental health problems in Palestinian schoolchildren. Thus 349 children aged 6-15 years were randomly selected from 23 schools in Gaza and the West Bank and were rated by their parents and teachers using both the ADHD DSM-IV Checklist and the Strengths and the Difficulties Questionnaire, which also measures conduct and emotional problems. There was a significant agreement between parents and teachers, with 4.3% of the children rated above the established cut-off scores on both the parent and teacher DSM-IV Checklist. Male gender, family size and living in an area of socioeconomic deprivation were independently associated with ADHD symptoms.

Behavioural and emotional problems in Iranian children four years after parental death in an earthquake.

BACKGROUND: Although previous research has established a direct impact of natural disasters on child mental health, there is limited knowledge on the underpinning mechanisms, particularly when there has been the loss of a parent. AIMS: To establish: (a) the rates of behavioural and emotional problems of school-aged children who had lost their parents in the 2003 earthquake in Iran, compared with children from intact families who attended the same schools; (b) the relationship between the psychopathology of the surviving parents' and children's behavioural and emotional problems; and (c) whether this relationship was compounded by socioeconomic factors. METHODS: Eighty six children of 7-13 years who had lost a parent in the earthquake four years earlier were compared with 80 matched children from intact families. The teacher and parent versions of the Strengths and Difficulties Questionnaire (SDQ) were used as measures of behavioural and emotional problems. Parents' psychopathology was established by the Self Report Questionnaire (SRQ). RESULTS: Behavioural and emotional problems were significantly higher in children who had suffered parental loss than in the control group. There was a significant association between parent-rated SDQ and SRQ scores. Parental death was found to interact with socioeconomic variables in predicting children's behavioural and emotional problems and surviving parents' mental health problems. CONCLUSIONS: After natural disasters, bereaved children and their surviving parents are at risk of developing mental health problems, and social adversities increase this risk.

Attention deficit-hyperactivity symptoms among Palestinian children

We aimed to establish the prevalence and distribution of attention deficit-hyperactivity disorder [ADHD] symptoms and other associated comorbid mental health problems in Palestinian schoolchildren Thus 349 children aged 6-15 years were randomly selected from 23 schools in Gaza and the West Bank and were rated by their parents and teachers using both the ADHD DSM-IV Checklist and the Strengths and the Difficulties Questionnaire, which also measures conduct and emotional problems. There was a significant agreement between parents and teachers, with 4.3% of the children rated above the established cut-off scores on both the parent and teacher DSM-IV Checklist. Male gender, family size and living in an area of socioeconomic deprivation were independently associated with ADHD symptoms

Parenting support and PTSD in children of a war zone.

BACKGROUND: The protective role of parenting factors on the mental well-being of children exposed to war trauma remains an under-researched area. AIM: To establish the relationship between perceived positive parenting support and post-traumatic stress disorder (PTSD) symptoms in children exposed to war trauma. METHODS: A random sample of 412 children aged 12-16 years was selected from the Gaza Strip and was assessed using the Gaza Traumatic Events Checklist (GTEC), the SCID (DSM-IV) and the Perceived Parenting Support Scale (PPSS). RESULTS: Palestinian children were exposed to different types of war-traumatic events. The number of exposed traumatic events was independently associated with the severity of post-traumatic symptoms scores or the diagnosis of PTSD, while perceived parenting support was found to act as a protective factor in this association. CONCLUSIONS: Interventions in war zones need to ensure the minimal possible disruption to communities and family units, and to involve parents in preventive or treatment programmes for children exposed to trauma.

Children's specific fears.

BACKGROUND: Most children experience some degree of fear during their development. Specific fears are considered as an appropriate response provided that they are proportionate to the intensity of the perceived threat. Our aim is to present the prevalence of specific fears among children in the Great Britain, their socio-demographic correlates, in particular their association with ethnicity. METHODS: Data on the child's experience of specific fears were obtained from parents of a national representative sample of 5- to 16-year-olds using the Development and Well-Being Assessment. Biographic, socio-demographic and socioeconomic characteristics of the child and the family were included in the questionnaire. RESULTS: About one-third of children were assessed by their parents as having at least one of 12 specific fears. The most commonly reported fears were animals (11.6%), blood/injections (10.8%) and the dark (6.3%). Just less than 1% of all children were assessed according to International Classification of Diseases research diagnostic criteria as having a specific phobia. Biographic, socio-demographic and socioeconomic factors were independently associated with a greater likelihood of a child having particular fears. The most marked associations were fears of the dark, loud noises, imagined supernatural beings in younger children and fear of animals among girls and all non-white groups. CONCLUSIONS: Although fears are only labelled as phobias when they impair functioning and interfere with life, they can cause personal distress to children and also can interfere with their daily activities. Children's fears differ in nature across different ethnic groups. Culturally mediated beliefs, values and traditions may play a role in their expression.

Three-year follow-up of a family support service cohort of children with behavioural problems and their parents.

Abstract Background The aim of this study was to establish the medium-term (three-year) psychosocial outcome of children with behavioural problems and their parents, who had received an intervention from a family support service. Methods Forty families were traced at the three-year follow-up and agreed to participate. Pre- and post-intervention and follow-up measures were the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) and the Strengths and Difficulties Questionnaire (SDQ). Results The primary HoNOSCA outcome items (i.e. those initially targeted by the parenting intervention) of aggression/antisocial behaviour and family relationships were not found to have changed significantly from the baseline (but had not sustained the sort-term improvement following the intervention). Deterioration was found in other HoNOSCA items such as overactivity, self-harm, scholastic/language skills, emotional, and poor school attendance. When we compared pre-intervention with follow-up SDQ scores, there was no significant change on any scales, i.e. these had returned to the level reported at the time of the original referral to the family support service. Conclusions Following the intervention from a family support service, children and families reported a significant improvement in most outcome measures, predominantly child behaviour and family relationships. However, these improvements were either not sustained or there were additional difficulties at three-year follow-up. These could be related to various external and developmental factors. This lack of sustainable treatment effects for children with behavioural problems is consistent with previous research findings on parenting programmes.

Services for pre-school children with behaviour problems in a Midlands city.

OBJECTIVES: To study the services for pre-school children with behaviour problems in a Midlands city and the level of co-ordination and co-operation between providers. SETTING: A socially and ethnically diverse Midlands city in the UK. METHODS: Survey methods were employed with city health visitors in order to determine their role and identify service providers. Service providers from different agencies were interviewed and data collected related to service offered, materials used, theoretical basis of interventions, referrals to and from the service, inclusion and exclusion criteria and co-ordination and co-operation with other providers. Themes were identified related to the content and process of the services using qualitative data analysis methods. Frequencies of themes were estimated for different provider groups. RESULTS: Health visitors and nursery nurses working in the primary care services were the primary point of contact for children with pre-school behaviour problems. Nursery nurses were one of the major sources of referral for children with pre-school behaviour problems and a significant majority of these providers had not received any specific training for this role. The majority of the providers used evidence-based programmes but few adhered strictly to a particular programme and instead used a mixture of materials drawn from different programmes. Many health service providers in particular offered interventions to parents on a one-to-one basis only. Most providers used behaviour modification approaches. While many providers claimed to have knowledge of other local providers and have good links, there was little evidence of co-ordination within and between agencies. CONCLUSIONS: While there appears to be high levels of activity by providers from both statutory and voluntary sectors in providing services for pre-school children with behaviour problems, there is evidence to suggest that some of the main providers of services are not being adequately prepared and supported in the role. There is a lack of co-ordination within and between services, and indication that evidence-based programmes are being modified and used in an ad hoc manner. It is concluded that surveys of this nature may be an important preliminary step in establishing co-ordinated services for the primary and secondary prevention of pre-school behaviour problems.

Pattern of semantic errors in autism: a brief research report.

Semantic or vocabulary errors were measured among children with autism and mild learning disability and children with mild learning disability only (six children of 7.9-8.7 years in each group), testing the hypothesis that these were common in both groups. Different variables were investigated such as breadth of vocabulary and number of vocabulary errors, type of paraphasias, and mechanisms used to name the meanings that children were not aware of or could not recall, and the particular meanings that were difficult for each group. Preliminary findings showed that vocabulary errors were similar in both groups, except under-extension, which was not used by the autism group. Children with autism tended to use all mechanisms in order to name something they did not know and to focus on parts of the object in order to name it, while unknown words were similar in both groups.