Monday, September 28, 2009

Parental Education Program Improves Mental Health and Adjustment in Parents of Children with Autism

Research indicates that parents of children with autism experience a high level of stress. Parent training interventions reflect an attempt to address this stress and improve parental mental health. In Tonge et al.’s (2006) study, parents of preschool children recently diagnosed with autism were sampled from four geographically separate metropolitan and rural regional assessment services for young children suspected of having autism. The sample was assigned to either the intervention group (n=70) or control group (n=35). Parents from the intervention group were further randomly assigned to a parent education and behavior management (PEBM) group (n=35) or a parent education and counseling (PEC) group (n=35). Subjects were administered a questionnaire at pre-intervention, post-intervention, and six-month follow-up. Parental health was determined using the General Health Questionnaire, a widely-used reliable, and valid self-administered adult screening test designed to detect mental health issues in community settings. Results showed that both interventions improved the mental health and well-being of parents with children recently diagnosed with autism, especially among parents who had preexisting mental health problems. There were no statistically significant results supporting the superiority of either PEBM or PEC.

The authors anticipate several potential threats to validity, and attempt to minimize these threats through the study design. First, by sampling populations in geographically distant rural and urban communities, the investigators attempted to control cross-contamination of groups as a threat to validity. Second, the investigators made attempts to control for any threats to internal or construct validity by training therapists to strictly follow guidelines for the specific interventions and providing supervision and training to therapists throughout the study. Therapists also administered both treatments and were rotated between therapies. The investigators videotaped a random 10% of the intervention group for content review and intervention adherence. Third, the authors address timing of measurement as a potential threat to external validity by testing all subjects six months after the study. Consequently, results showed that alleviation of symptoms became more apparent over the long-term, reflecting a possible cumulative effect of treatment. Nevertheless, the study also exhibits limitations. By selecting samples from rural and urban communities, access to services may have created notable differences between the groups. Because parents were included in the study based on their children’s diagnosis, the group may exhibit wide variation in regards to mental health. This diversity of subject characteristics made it difficult for the investigators to determine a difference between groups. Overall, the study reveals promising findings about the effectiveness of parent training as an important element of interventions for children with autism.

Reference:
Tonge, B., Brereton, A., Kiomall, M., Mackinnon, A., King, N., and Rinehart, N. (2006). Effects of parental mental health of an education and skills training program for parents of young children with autism: A randomized control trial. Journal of the American Academy of Child and Adoelscent Psychiatry, 45(5), 561-569.

Mind-Body Skills Intervention Decreases Symptoms of Post-Traumatic Stress Disorder in Postwar Kosovar Adolescents

Incidence of post-traumatic stress disorder (PTSD) has been reported among war-affected children and adolescents. Yet few studies have evaluated the effectiveness of PTSD treatment programs for this population. Gordon, et al. (2009) conducted a randomized control trial to determine the effectiveness of an intervention aimed at ameliorating the effects of PTSD in adolescents. All children in Jeta e Re (“New Life”) High School in Kosovo were screened to participate in the study. Eighty-two students met the criteria for PTSD and were randomly assigned to two groups: (a) intervention group and (b) delayed intervention group. The intervention group participated in a comprehensive mind-body skills group program, a 12-session program consisting of meditation, guided imagery, breathing exercises, relaxation activities, therapeutic discussion, and art therapy. The delayed intervention group received the same intervention once the intervention group had completed the program, approximately 6 weeks later. The study shows that students receiving the mind-body skills group program had significantly reduced levels of PTSD symptoms as compared to the delayed intervention control group.

This study is the first randomized control study to examine the effects of a therapeutic intervention on war-affected adolescents. The study design overcomes the ethical dilemma of withholding promising treatment from the control group by providing treatment to the control group after the intervention group has completed post-intervention interviews. Nevertheless, expectation bias poses a threat to the study’s internal validity, because the results of the improved outcomes may be due to the participants’ expectations that the intervention would be effective. This threat to internal validity is supported by the fact that the intervention was piloted in the school prior to the study, building even more anticipation, as students are bound to share their experiences with other students. This is also be related to the process of testing, which could be a threat to internal validity, because students may become familiar with the measures being used. Because teachers both facilitated the intervention and administered the measures, unintentional expectancy effects pose a threat to the study’s construct validity. In this case, teachers may have subconsciously expected students to show fewer PTSD symptoms in the post-test. Similarly, the students may have wanted to please the facilitators by showing improvements in the post-test. Despite the authors’ explanation that these students would only be comfortable speaking with a familiar adult, future studies should utilize external experimenters to administer the pre- and post-test, because they will be na├»ve to which students received the intervention and will have no vested interest in the outcome of the intervention.


Reference:
Gordon, J.S., Staples, J.K., Blyta, A., Bytyqi, M., and Wilson, A.T. (2008). Treatment of posttraumatic stress disorder in postwar Kosovar adolescents using mind-body skills groups: A randomized controlled trial. Journal of Clinical Psychiatry, 69(9), 1469-1476.

Tuesday, September 22, 2009

Combination of Education and Trauma Healing Activities Decreases Trauma Symptoms in War-Affected Children in Sierra Leone

Though research indicates that higher levels of traumatic events among war-affected children leads to greater incidence of negative mental health outcomes, there is little evidence about the effectiveness of psychosocial interventions to mitigate these consequences. Gupta and Zimmer (2008) focus on determining the effectiveness of a psychosocial intervention study among children affected by the conflict in Sierra Leone. The sample was randomly drawn from school registration lists provided by the Ministry of Education, which contains all school-age children residing in the Grafton and Trade Center camps for internally displaced persons. The sample focused on an equal number of boys and girls ages 8-17, for a total sample size of 315 children. The Rapid-Ed intervention consisted of an education module enhanced with eight sessions of structured trauma healing activities and unstructured recreation activities. Children were interviewed for the pre- and post-test by trained camp teachers using a semi-structured questionnaire, which was translated and back-translated into the local language (Creole). The pre-test was administered approximately 9-12 months after the start of armed conflict, and the post-test was administered 4-6 weeks after participants completed the intervention. Results show that 96% of children reported a significant reductions in concentration problems, sleep disturbances, bad dreams, and intrusive images after participating in the Rapid-Ed intervention. The study also found that there was a slight increase in avoidance symptoms after the intervention.

The study addresses selection bias by randomly selecting children from the target communities. Also, the low attrition rate (3%) was a strength, and most likely due to the accessibility and reliability of finding the students in formal schooling programs. However, the results of this study would be strengthened with the addition of a control group. Use of a control group would indicate whether it was the intervention that caused the decreased psychological distress or whether other factors were responsible. Firstly, maturation poses a threat to the internal validity, because the study is unable to discern whether the intervention was the cause of improved psychosocial outcomes or whether it was due to the subjects’ internal healing processes. Secondly, statistical regression may pose a threat to the internal validity, because the change due to the intervention cannot be distinguished from the effect of scores reverting toward the mean. A control group would have addressed these concerns and greatly improved the study’s internal reliability. However, the sensitive context creates ethical challenges in regards to whether one group can receive the intervention and the other one doesn’t.

Reference:
Gupta, L. and Zimmer, C. (2008). Psychosocial intervention for war-affected children in Sierra Leone. The British Journal of Psychiatry, 192, 212-216.

Monday, September 21, 2009

Longitudinal Research Finds Sibling Relationships as Protective for Children Who Experience Stressful Life Events

Prior research indicates that children who experience stressful life events are at risk of developing emotional difficulties and displaying internalizing behavior, yet few studies have looked at the sibling relationship as a moderating factor against these risks. Furthermore, there is conflicting research examining the link between stressful life events and externalizing behaviors. The authors conducted a two-wave longitudinal study to determine the extent to which sibling relationship moderates risks in siblings experiencing stressful events. Data were gathered through the Avon Longitudinal Study of Parents and Children (ALSPAC), with a total of 196 families agreeing to participate after meeting the selection criteria. Interviews were conducted with families twice: first, at baseline and again, two years later. Interviews measured number and qualtity of stressful life events, quality of sibling relationship, quality of mother-child relationship, children’s externalizing and internalizing behaviors, socioeconomic status, age, and gender. The study found that positive sibling relationships positively influenced the relationship between stressful life events and internalizing symptomatology, but not the relationship between stressful life events and externalizing symptomatology. The study also found that the protective effect is not dependant upon the quality of the mother-child relationship.

This study is the first of its kind. No other study has examined if sibling relationships are protective for children who experience stressful life events. The choice of a longitudinal design was a strength, because the results are more likely to be attributed to a causal relationship between the positive sibling relationship and the amelioration of internalizing symptomatology. Also, the measures utilized the responses of multiple respondents, making a more accurate determination of scale. However, there may be plausible rival hypotheses due to variables that may not have been included in the research. Maturation may be a threat to internal validity, as children who are two years older might show improved internalizing behaviors. This study would have improved with the implementation of a control group of children who experience stressful events, but do not have a sibling. The control group would have evidenced that the protective effect of the sibling relationship is responsible for decreased internalizing behaviors.

Reference:
Gass, K., Jenkins, J., and Dunn, J. (2007). Are sibling relationships protective? A longitudinal study. Journal of Child Psychology and Psychiatry, 48(2), 167-175.

Friday, September 18, 2009

Class Society and Structure

Marx and Engels’ (1952) most renowned statement – that which opens Manifesto of the Communist Party – reads, “The history of all hitherto existing society is the history of class struggles” (p. 473). The dawn of capitalism has greatly increased production, yet Marx and Engels argue that this increase of wealth has not been distributed evenly to the detriment of the working class poor. The system operates narrowly, with the only focus on increasing property and wealth trickling up to benefit the upper class. Marx and Engels assert that the more wealth the worker produces - “the more his production increases in power and scope” (p. 133) - the poorer he becomes.

This message resonates today. In many societies, the struggles of the poor and inequalities of power are a matter of life or death. The impoverished pregnant women who is unable to access health care, the worker who is not paid a living wage, the young girl who is denied access to education all provide examples of structural inequality, which have dire circumstances for life outcomes. This unequal distribution of “wealth” (e.g., health care access, wages, education) leads to decreases in quality of life and increases in morbidity and mortality.

Those who struggle are acutely aware of the injustices they experience, with struggle influencing each of their worldviews. Mills (1959) remarks that individuals are greatly influenced by the world around them: “What ordinary men are directly aware of and what they try to do are bound by the private orbits in which they live” (p. 3). In other words, they work within structures, but are also at the mercy of these structures. Mills refers to “personal troubles of the mileau” (p. 8) related to internal mechanisms as opposed to “public issues of social structure” (Ibid). The latter can become a form of “structural violence” (Farmer, 2005), forces of poverty, racism, and socioeconomic inequality that impact impoverished populations. Structural violence represents existing constructions such as gender, religion, race, or class that may shape risk and influence an individual’s life outcome. This concept is often oversimplified as inequality, but it is actually a much stronger and prevalent force that persists day-to-day, transnationally. Structural violence includes the result of the inequality - marginalization, discrimination, stigma, restricted access, victimization - and the context in which inequalities develop and are addressed.

Structural violence is a helpful mechanism to view class society and structure because it focuses on the societal factors outside of the individual’s control. In order to overcome structural barriers, social work interventions must understand and address the complex social issues that keep individuals from utilizing their full resources, understanding that these social issues are weighed differently in different settings. Empowerment of individual agency, fortification of communities, and an increase in access to social services combined with an understanding of existing structural barriers add to our understanding and denouncement of systems, structures, and mechanisms that create conditions where the rich get richer and the poor get even poorer.

References:
Farmer, P. (2005). Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley, CA: University of California Press.
Marx, K. and Engels, F. (1952). Alienation and social class. In. R.C. Tucker (Ed.) (1978), The Marx-Engels Reader. New York, NY: W.W. Norton and Company, p. 133-135.
Marx, K. and Engels, F. (1952). Manifesto of the communist party. In. R.C. Tucker (Ed.) (1978), The Marx- Engels Reader. New York, NY: W.W. Norton and Company, p. 473-500.
Mills, C.W. (1959). The promise. In C.W. Mills, Sociological Imagination. New York, NY: Oxford University Press.

Tuesday, September 15, 2009

Study in Afghanistan Finds Trauma Exposure and Caregiver Mental Health Predict Risk of Negative Mental Health Outcomes in War-Affected Youth

Research conducted in war-affected situations has found an association between exposure to traumatic events and mental health outcomes. However, there have been few studies focusing on the mental health outcomes of children and adolescents affected by war. Panter-Brick, et al. (2009) conducted a study aimed at determining a causal relationship between war and mental health problems, specifically looking at associations related to gender, traumatic events, caregiver mental health, and socio-demographic characteristics. The sample targeted children ages 11 to 16, who were randomly drawn from randomly selected schools in three purposively chosen regions of Afghanistan. Data were gathered from three informants (children, caregivers, and teachers), who were interviewed with a variety of brief measures. Measures were chosen because they had high reliability in other contexts of instability. To increase instrument diagnostic validity, measures were translated, back-translated, and reviewed by a multi-disciplinary team. The research found that the variables of exposure to multiple trauma and caregiver mental health were predictive of psychopathology for in-school Afghan adolescents. Previous research corroborates this finding and adds to the study’s external validity. Furthermore, the study found that girls were more likely than boys to develop poor mental health outcomes, such as depression.

The authors explore the quality of traumatic events to include not just war-related events, but accidents, corporal punishment, illness, death of a relative. The quality of the particular incident is not indicative of predicting poor mental health, but rather the accumulation of traumatic events contribute to risk factors for mental health problems. The study includes a few threats to validity. By only sampling school children, the study neglects out-of-school youth, who may be at high risk of developing psychopathology. Furthermore, even though the sample of in-school youth was stratified to include accurate proportions of boys and girls, the focus on in-school youth disproportionately excludes girls, because boys are more likely to attend school than girls. The school samples were restricted to three urban areas, affecting external validity and indicating that future research might consider including a sample from a rural setting. Despite its limitations, this study indicates the value of working within the school system to assess children’s mental health needs and proves the value of school-based mental health services. Furthermore, the findings contribute to the small but much needed knowledge base about the mental health of war-affected children.

Reference:
Panter-Brick, C., Eggerman, M., Gonzalez, V., and Safdar, S. (2009). Violence, suffering, and mental health in Afghanistan: a school-based survey. The Lancet, 374, 807-816.

Quality of Parental Involvement More Relevant Than Use of Child Corporal Punishment in Development of Negative Adolescent Outcomes

Child development researchers have long suggested that corporal punishment is a predictor of negative behavioral outcomes in children. However, because they suffer from serious methodological limitations, studies on the effects of corporal punishment have yet to definitively determine if corporal punishment is causally related to negative adolescent outcomes. In this study, the authors attempt to determine the extent that quality of parental involvement and corporal punishment independently predict adolescent maladjustment, specifically adolescent aggressiveness, delinquency, and psychological well-being. The authors used a prospective study design, interviewing 332 families annually over a three-year period. Interviews consisted of parent self-reports, adolescent reports, and observed ratings of family interaction tasks. Corporal punishment was determined by time (i.e., consistent use of physical discipline over the three-year study period), age-appropriateness (i.e., continuing during adolescence, indicating harsh discipline), and type (i.e., use of object, being shoved or pushed.) Quality of parental involvement was determined by display of warmth and affection, monitoring and supervision, consistency of discipline, and use of inductive reasoning to explain rules and expectations. The authors found that once other dimensions of parenting are controlled for, there exists a significant relationship between quality of parental involvement and adolescent outcomes. Contrary to past research on this topic, the study found no significant relationship between corporal punishment and the adolescent outcomes.

This study’s main strength lies in its design aimed at isolating other parenting behaviors to determine that quality of parental involvement, rather than corporal punishment, was a predictor of maladaptive behavior among adolescents. The study’s use of self-reports from parents and adolescents, combined with observation of family interactions, created a more comprehensive depiction of family interaction. However, the sample selection presents some limitations to the study. Firstly, the sample represents a rural population, highlighting the need for the study to be replicated in an urban setting. Furthermore, though 451 families were recruited for the study, only 404 families completed all four waves, 19 families were not eligible after divorcing during the study period, and there was incomplete data for 53 of the families. Secondly, the authors emphasize that corporal punishment should not be confused with physical abuse, for in this study, the corporal punishment wasn’t extreme enough to be considered physical abuse; therefore, additional studies should be conducted to examine the effects of physical abuse on adolescent outcomes, independent of other parental behaviors. Thirdly, there might be other adolescent dimensions not addressed in this study that would be important indicators of maladjustment; the authors suggest looking at autonomy, self-reliance, and creativity in future research.

Reference:
Simons, R.L., Johnson, C., and Conger, R.D. (1994). Harsh corporal punishment versus quality of parental involvement as an explanation of adolescent maladjustment.
Journal of Marriage and the Family, 56(August 1994), 591-607.

Thursday, September 10, 2009

Historical Roots of Community Engagement and Mobilization

Programs for disadvantaged populations risk encouraging passivity and creating dependency, which are adverse to recovery and sustainability. Social settlements, one of the cornerstones of modern social work, were founded on the tenet of collective action built on a basis of trust and cooperation with community members and local institutions to improve community life. The first settlement house was developed in late 19th-century London as a response to growing numbers of people living in poverty, especially immigrants. Soon thereafter, Jane Adams developed a settlement house in the United States, Chicago’s Hull House, which quickly took on several vital roles within the community – a center for social activity and learning, with youth clubs, women’s clubs, athletic classes, and college extension classes, as well as community advocacy. Though Adams’ settlement house movement did not only target vulnerable populations but rather “all sides of neighborhood life”, it is regarded as the starting point of social services to address the needs of the vulnerable within the community. Adams (1892) essay “The Objective Value of a Social Settlement” focuses on the tenets behind the settlement model, most importantly providing people with opportunities so they can help themselves, rather than relying on charity. Likewise, Agnew’s (2004) chapter on Mary Richmond, tells of her discouraging begging and handouts and focusing on educational and employment opportunities for the needy. Both emphasize that drawing upon all the resources that social programs offer as well as the resources of the community allows for collective strength and cooperation.

In the field of international child protection, community engagement and mobilization around the needs of children has always been key to creating a protective environment for children. For example, Richmond engaged with the community to safeguard children’s interests around regulating child labor. When a community is engaged to identify the needs of children in their community, children are prioritized. Collective planning facilitates the empowerment of adults and creates a sense of autonomy in uncertain and disempowering circumstances. Even in emergencies, communities still maintain structures and capacities for coping, aligned with their ideals, values, and relationships. Although pre-crisis coping mechanisms may be undermined during times of crisis, the community does not lose its capacity for developing solutions and rebuilding community life. Wessells and Monteiro (2008) suggest using an empowerment model rather than a service model to connect with the community in a front-line response to create a protective environment for young children and aid in their own recovery. Psychologically, part of community recovery is a reinstatement of collective efficacy and action to help monitor and reduce risks and prevent abuse and exploitation. In this way, caregiving structures for children in the community are strengthened. When the capacity of communities to recovery from crisis is recognized, feelings of hope and autonomy are increased. As Adams (1893) says, “They require only that their aspirations be recognized and stimulated, and the means of attaining them put at their disposal” (p. 61).

References:
Adams, J. (1893). The objective value of social settlement. In C. Lasch (1982), The Social Thought of Jane Adams. New York, NY: Irvington Publishers, p.44-61.
Adams, J. (1915). Subjective necessity for social settlements. In Twenty Years at Hull House. New York, NY: The Macmillan Company, p. 113-127.
Agnew, E. (2004). Families and the circle of reform. In From Charity to Social Work: Mary E.
Richmond
and the Creation of an American Profession. Ubana, IL: University of Illinois Press,
p. 95-131.

Wessells, M. and Monterio, C. (2008). Supporting young children in conflict and postconflict
situations:
Child protection and psychosocial well-being in Angola. In M. Garcia, A. Pence, and
J. Evans (Eds.), Africa’s future, Africa’s challenge: Early childhood care and development in
sub-Saharan Africa (pp.317-329). Washington, DC: World Bank.


Tuesday, September 8, 2009

Preventive Interventions Help Secure Attachment in Maltreated Infants

Child maltreatment presents threats to child developmental processes, including long-term maladjustment and development of psychopathology. Cicchetti, Rogosch, and Toth’s (2006) study examines the effectiveness of two preventive interventions: psychosocial parenting education (PPI) and infant-parent psychotherapy (IPP). Based on the theory that secure attachment is derived from parental knowledge and skills, PPI involves a series of psychoeducation-focused home visits with mothers to improve parenting skills, increase mothers’ knowledge of child development, and enhance coping and social support skills. IPP is based on attachment theory and includes an exploration of the parent-child relationship through therapy. The hypothesis that PPI or IPP interventions will be most effective for ameliorating the effects of maltreatment of infants is explored in this study. The study sampled mothers and their infants in maltreating families (n=137). Subjects were randomly assigned to one of three cohorts: (1) psychosocial parenting education (PPI), (2) infant-parent psychotherapy (IPP), or (3) community standard (CS). A normative comparison (NC) group of non-maltreated infants and their mothers (n=52), with similar demographics to the intervention group, was also included. Using validity tested measures, the authors found that mothers and children in the PPI and IPP groups showed greater increases in secure attachment than mothers and children in the CS and control groups. This study supports evidence that preventive intervention programs can alter attachment organization and ameliorate the negative developmental consequences of maltreatment.

As compared to results from the CS group, the authors provide evidence that the PPI and IPP interventions result in greater increases of secure attachment in maltreating families. However, the non-maltreating control group varied greatly from the maltreating group, with maltreating mothers reporting higher rates of maltreatment in their own childhoods, more insecure relationships with their mothers, more maladaptive parenting attitudes, more parenting stress, and lower family support. Similarly, despite trying to maintain uniform adherence to the therapeutic intervention, the therapy was not completely standardized, because the intervention used different therapists. Lastly, the intervention groups were actively pursued to follow the therapy schedule, which is not commonly done in treatment modalities such as the CS group.
The authors attempt to eliminate any self-selection bias, by seeking out maltreating families rather than the families seeking to be enrolled in the study.

Reference:
Cicchetti, D., Rogosch, F.A., and Toth, S.L. (2006). Fostering secure attachment in infants in maltreating families through preventive interventions. Development and Psychopathology, 18, 623-649.

Child-Centered Spaces are Beneficial to Young Children Affected by War in Northern Uganda

A widely used approach to aid children and their families in emergencies is the implementation of child-centered spaces (CCSs), which are physical spaces providing structured activities and support for children and their caregivers in emergencies. Despite the prevalence of CCSs, there has been little systematic research to assess their impact. Kostelny and Wessell’s (2008) evaluation of safe spaces in an internally displaced persons (IDP) camp in northern Ugandan is the first of its kind. The study uses both qualitative and quantitative methods to determine if CCSs protect young children (3-6) from risks and threats in their environment, improve children’s psychosocial well-being, and increase children’s knowledge and life-skills levels. Qualitative data were collected from focus group discussions with 92 caregivers and community members. Qualitative data informed development of a tool based on locally-derived indicators of child well-being in the northern Uganda context. Using the locally derived indicators and a Western developed screening tool for emotional and behavioral difficulties, quantitative data were collected from interviews with caregivers. The study randomly selected 176 caregivers of children attending CCS program and 118 caregivers randomly selected from a nearby IDP camp where there were no CCS services available. Significant benefits for children in the CCSs occurred within the domains of protection, psychosocial well-being, and life skills. The authors conclude that if positive effects can occur in as challenging an environment as northern Uganda, then the implementation of CCSs might have similar positive effects in other difficult settings.

This study uses locally appropriate measures to bypass questions of validity inherent in Western measures’ application to non-Western settings. Furthermore, the study focuses on outcomes versus process indicators, which rarely describe the actual benefits of a program in regards to child development, protection, and well-being. Nevertheless, the authors recognize limitations to their study. First, intervention and control groups weren’t systematically matched. Secondly, because the data rely on self-reports, the study may have experienced self-preservation bias with the intervention group reporting more favorable outcomes. Lastly, the external validity of the findings should be considered with caution, since this evaluation only addresses one specific context. In order to gain support that child-centered spaces are beneficial for children in crisis settings, more research must be conducted in other contexts.


Reference:
Kostelny, K. and Wessells, M. (2008). The protection and psychosocial well-being of young children following armed conflict: outcome research on child-centered spaces in northern Uganda. The Journal of Developmental Processes, 3(2), 13-25.