Preventing Adolescent Cigarette Smoking

Recent studies have supported the efficacy of approaches to smoking prevention that focus primary attention on social and psychological factors implicated in initiation of adolescent cigarette smoking. This article reports first year data from a large-scale smoking prevention study conducted within three geographic regions of New York State. The sample consists of 5,954 seventh graders from 56 middle/junior high schools. Schools were randomly assigned to (1) receive the Life Skills Training (LST) prevention program with a one-day teacher training workshop; (2) receive the LST prevention program with teacher training provided by video tape; or (3) serve as a comparison group. This study was designed to further test the efficacy of this type of smoking prevention program and to compare the relative effectiveness of two different types of provider training in an effort to learn more about the potential effectiveness of this prevention strategy when implemented under "real world" conditions. Pretest and posttest data were collected by questionnaire concerning self-reported tobacco use and several hypothesized mediating variables. Results indicate that the prevention program significantly impacted on several hypothesized mediating variables in a direction consistent with non-smoking. Within one region, the students in both experimental conditions reported significantly less current cigarette smoking and reported themselves less likely to smoke in the future than the students in the control condition.     

Ethical considerations in psychotherapy effectiveness research: choosing the comparison group

The primary purpose behind effectiveness research is to determine whether a treatment with demonstrated efficacy has utility when administered to the general population. The main questions these studies are meant to answer are these: Can the typical patient respond to treatment? Is the treatment acceptable to the typical patient? Can the treatment be administered safely and in its entirety in the typical treatment setting? Is the treatment under study significantly better than the community standard of care both from and a cost and outcome perspective? Answering these questions is meant to provide sufficient information to providers and policymakers so that effective interventions can be adopted and become the new community standard. For this research to make a meaningful impact on a provider and policymaker's decision to change the status quo, study interventions should be compared to the existing community standard of treatment, often referred to as treatment as usual (TAU). From an ethical perspective, this decision may not always be the safest choice. In some populations, TAU may mean no treatment at all, and in others TAU may be worse than withholding treatment. The effectiveness researcher is then caught between the pull to do no harm and the need for research to have an impact on change. The purpose of this article is to highlight certain conditions when TAU is ethically acceptable and to discuss alternatives when TAU may be an unethical treatment condition. For purposes of precision, we focus exclusively on psychotherapy effectiveness research rather than system-intervention research or medication-intervention research.     

Ethical Considerations in Psychotherapy Effectiveness Research: Choosing the Comparison Group

The primary purpose behind effectiveness research is to determine whether a treatment with demonstrated efficacy has utility when administered to the general population. The main questions these studies are meant to answer are these: Can the typical patient respond to treatment? Is the treatment acceptable to the typical patient? Can the treatment be administered safely and in its entirety in the typical treatment setting? Is the treatment under study significantly better than the community standard of care both from a cost and outcome perspective? Answering these questions is meant to provide sufficient information to providers and policymakers so that effective interventions can be adopted and become the new community standard.

For this research to make a meaningful impact on a provider and policymaker's decision to change the status quo, study interventions should be compared to the existing community standard of treatment, often referred to as treatment as usual (TAU). From an ethical perspective, this decision may not always be the safest choice. In some populations, TAU may mean no treatment at all, and in others TAU may be worse than withholding treatment. The effectiveness researcher is then caught between the pull to do no harm and the need for research to have an impact on change. The purpose of this article is to highlight certain conditions when TAU is ethically acceptable and to discuss alternatives when TAU may be an unethical treatment condition. For purposes of precision, we focus exclusively on psychotherapy effectiveness research rather than system-intervention research or medication-intervention research.     

Are explanatory trials ethical? Shifting the burden of justification in clinical trial design

Most phase III clinical trials today are explanatory. Because explanatory, or efficacy, trials test hypotheses under “ideal” conditions, they are not well suited to providing guidance on decisions made in most clinical care contexts. Pragmatic trials, which test hypotheses under “usual” conditions, are often better suited to this task. Yet, pragmatic, or effectiveness, trials are infrequently carried out. This mismatch between the design of clinical trials and the needs of health care professionals is frustrating for everyone involved, and explains some of the challenges inherent in attempts to enhance knowledge translation and encourage evidence-based practice. The situation is more than simply frustrating, however; it is potentially unethical. Clinical trials must be socially valuable in order to (1) warrant the risks they impose on human research subjects and (2) fairly and efficiently assess new clinical interventions. Most bioethicists would agree that trials that have no social value, for instance, because their results do not have the potential to advance clinical care, should not be performed. What is less widely appreciated is that given limited research resources, trials that are more socially valuable should be preferred to trials that are less socially valuable when all else is equal. With respect to clinical trial design, I argue that while explanatory trials often have some social value, many have less social value than their pragmatic counterparts. On the basis of this general ethical assessment, I provide a preliminary defense of the position that clinical researchers should aim to conduct pragmatic trials, that is, that researchers face a burden of justification related to any idealizing elements added to trial designs.     

Evaluation of a High School Peer Group Intervention for At-Risk Youth

The purpose of this paper is to examine the effectiveness of Reconnecting Youth, a prevention program for at-risk high school youth. Data are from a large, independently evaluated effectiveness trial in two diverse urban school districts. A total of 1,218 students participated; 50% were male; average age was 15. We tested whether positive efficacy trial effects could be replicated, and whether any negative behavioral effects occur when clustering high-risk youth. Although mixed program effects were observed at immediate post-intervention, only negative effects were found at 6-month follow-up. These effects included less optimal scores on measures of GPA, Anger, School Connectedness, Conventional Peer Bonding, and Peer High-Risk Behaviors. Overall, we found little support for the use of this social-influence—model intervention aimed at increasing school connectedness for high-risk youth. Further, this study provides evidence that clustering high-risk youth in preventive interventions has the potential for iatrogenic effects.     

Group interventions for patients with cancer and HIV disease: part IV. Clinical and policy recommendations

Group interventions have assumed a growing role in primary prevention and supportive care for cancer and HIV disease. Earlier sections of this Special Report examined empirical findings for these interventions and provided recommendations for future research. The current section offers brief recommendations for service providers, policymakers, and stakeholders. Group services now occupy an increasingly prominent place in primary prevention programs and medical settings. In previous sections of this Special Report (Sherman, Leszcz et al., 2004; Sherman, Mosier et al., 2004a, 2004b) we examined the efficacy of different group interventions at different phases of cancer or HIV disease, considered characteristics of the intervention and the participants that might influence outcomes, and discussed mechanisms of action. Methodological challenges and priorities for future research were highlighted. In this, the final section, we offer brief recommendations for service providers, policymakers, and other stakeholders. We consider some of the barriers that constrain use of empirically-based group interventions and note how these programs might be implemented more widely and effectively.     

La recherche d’efficacité dans les actions de santé au travail. Le « travail sur le travail » comme alternative a la formation sur les risques psychosociaux

Based on a significant experience of interventions and research interventions in the field of occupational health, the authors wished, based on the assessment of several psychosocial risk prevention action plans, provide several reflections to build a risk-based alternative approach. This approach promoted “a work on a work” by the actors. This work becomes a source of knowledge and transformation. Here, the professionals in the field are not only informants on the work and adresses of recommendations, but also producers of knowledge, understood for them. The program presented involves the actors of work to overcome the obstacle of the transition from diagnosis to action.     

A likelihood ratio test for mixture effects

Under certain circumstances, it is theoretically important to decide whether a difference between two conditions in mean reaction time (RT) results from a relatively uniform slowing of all the responses in the slower condition or from a mixture of some slowed trials with some unslowed ones. This article describes a likelihood ratio test that can be used to differentiate between these two possibilities and reports computer simulations examining the power and Type I error rate of the test under conditions similar to those encountered in RT research. A freely available computer program, called MIXTEST, can be used both to carry out the likelihood ratio test and to conduct simulations evaluating the performance of the test within various settings.     

Dreams,Memories, Reflections by C. G. Jung

Abstract

Group interventions have assumed a growing role in primary prevention and supportive care for cancer and HIV disease. Earlier sections of this Special Report examined empirical findings for these interventions and provided recommendations for future research. The current section offers brief recommendations for service providers, policymakers, and stakeholders.

Group services now occupy an increasingly prominent place in primary prevention programs and medical settings. In previous sections of this Special Report (Sherman, Leszcz et al., 2004; Sherman, Mosier et al., 2004a, 2004b) we examined the efficacy of different group interventions at different phases of cancer or HIV disease, considered characteristics of the intervention and the participants that might influence outcomes, and discussed mechanisms of action. Methodological challenges and priorities for future research were highlighted. In this, the final section, we offer brief recommendations for service providers, policymakers, and other stakeholders. We consider some of the barriers that constrain use of empirically-based group interventions and note how these programs might be implemented more widely and effectively.     

The Survivor Health and Resilience Education (SHARE) Program: Development and Evaluation of a Health Behavior Intervention for Adolescent Survivors of Childhood Cancer

Few evidence-based health behavior interventions for adolescent survivors of childhood cancer currently exist. These interventions are necessary to address a range of lifestyle and behavioral factors (e.g., diet and physical activity, tobacco and alcohol use, excessive sun exposure) that may place survivors at increased risk for secondary cancers other chronic diseases. To address this need, the development and evaluation of a health promotion and disease prevention program for childhood cancer survivors is described, with an emphasis on the steps leading up to conducting a randomized controlled trial to test its efficacy. Data gathered from trial participants suggest the preliminary evaluation of the intervention is favorable. Trends and future directions in behavioral intervention research with childhood cancer survivors are discussed, along with the role of behavioral research in health promotion and disease prevention.     

Housing and Child Welfare: Emerging Evidence and Implications for Scaling up Services

Inadequate housing threatens family stability in communities across the United States. This study reviews emerging evidence on housing interventions in the context of scale‐up for the child welfare system. In child welfare, scale‐up refers to the extent to which fully implemented interventions sustainably alleviate family separations associated with housing instability. It incorporates multiple aspects beyond traditional measures of effectiveness including costs, potential reach, local capacities for implementation, and fit within broader social services. The framework further encompasses everyday circumstances faced by service providers, program administrators, and policymakers who allocate resources under conditions of scarcity and uncertainty. The review of current housing interventions reveals a number of systemic constraints for scale‐up in child welfare. Reliance on rental assistance programs limits capacity to address demand, while current practices that target the most vulnerable families may inadvertently diminish effectiveness of the intervention and increase overall demand. Alternative approaches that focus on homelessness prevention and early intervention must be tested in conjunction with community initiatives to increase accessibility of affordable housing. By examining system performance over time, the scalability framework provides an opportunity for more efficient coordination of housing services within and outside of the child welfare system.     

Common factors in the enhancement of dyadic coping

Stress and coping are important constructs in understanding the dynamics of close relationships. Couple therapy and marital distress prevention approaches have become increasingly focused on these variables to gain knowledge of how stress and coping may impact the quality and stability of close relationships. In this paper, we outline couple's coping enhancement training (CCET) and the coping-oriented couple's therapy (COCT); both, couple interventions derived from stress and coping research. We address specific features of each approach and report data on their efficacy and effectiveness. We also examine both the common and specific factors that may play a role in the effectiveness of these approaches.     

Review of Interventions to Improve Family Engagement and Retention in Parent and Child Mental Health Programs

Engaging and retaining families in mental health prevention and intervention programs is critically important to insure maximum public health impact. We evaluated randomized-controlled trials testing methods to improve family engagement and retention in child mental health programs published since 1980 (N = 17). Brief, intensive engagement interventions in which providers explicitly addressed families’ practical (e.g. schedules, transportation) and psychological (e.g. family members’ resistance, beliefs about the treatment process) barriers as they entered treatment were effective in improving engagement in early sessions. The few interventions found to produce long-term impact on engagement and retention integrated motivational interviewing, family systems, and enhanced family stress and coping support strategies at multiple points throughout treatment. Few interventions have been tested in the context of prevention programs. There are promising approaches to increasing engagement and retention; they should be replicated and used as a foundation for future research in this area.     

Interventions for children and adolescents who stutter: A systematic review,meta-analysis,and evidence map

PurposeThis systematic review critically appraises and maps the evidence for stuttering interventions in childhood and adolescence. We examine the effectiveness of speech-focused treatments, the efficacy of alternative treatment delivery methods and identify gaps in the research evidence.MethodsNine electronic databases and three clinical trial registries were searched for systematic reviews, randomised controlled trials (RCTs) and studies that applied an intervention with children (2–18 years) who stutter. Pharmacological interventions were excluded. Primary outcomes were a measure of stuttering severity and quality assessments were conducted on all included studies.ResultsEight RCTs met inclusion criteria and were analysed. Intervention approaches included direct (i.e. Lidcombe Program; LP) and indirect treatments (e.g. Demands and Capacities Model; DCM). All studies had moderate risk of bias. Treatment delivery methods included individual face-to-face, telehealth and group-based therapy. Both LP and DCM approaches were effective in reducing stuttering in preschool aged children. LP had the highest level of evidence (pooled effect size=-3.8, CI -7.3 to -0.3 for LP). There was no high-level evidence for interventions with school-aged children or adolescents. Alternative methods of delivery were as effective as individual face-to-face intervention.ConclusionThe findings of this systematic review and evidence mapping are useful for clinicians, researchers and service providers seeking to understand the existing research to support the advancement of interventions for children and adolescence who stutter. Findings could be used to inform further research and support clinical decision-making.     

Alternative Methodologies in Research Literature Review: Links Between Clinical Work and MFT Effectiveness

Traditionally, "good outcome research" has referred to laboratory-based, controlled studies that report the efficacy of a given treatment on a specific population. Although useful and needed in the struggle to establish MFTs as accepted mental health service providers, this type of research does not address whether MFT is effective in "real world" settings. In order to highlight the clinical and professional relevance of existing effectiveness research, this article reviews 15 years of clinical research in three major family therapy journals. The results suggest that 1) MFT effectiveness is under-represented in major review articles, 2) clinicians can use a variety of methodologies to establish the effectiveness of their work, and 3) more research is needed that investigates how and why MFT works in "real world" settings. Implications for practice and future research are discussed.     

Promoting and protecting youth mental health through evidence-based prevention and treatment

For decades, empirically tested youth interventions have prevented dysfunction by addressing risk and ameliorated dysfunction through treatment. The authors propose linking prevention and treatment within an integrated model. The model suggests a research agenda: Identify effective programs for a broadened array of problems and disorders, examine ethnicity and culture in relation to intervention adoption and impact, clarify conditions under which programs do and do not work, identify change mechanisms that account for effects, test interventions in real-world contexts, and make tested interventions accessible and effective in community and practice settings. Connecting the science and practice of prevention and treatment will be good for science, for practice, and for children, adolescents, and their families.     

Postpartum Depression in Mothers and Fathers: The Role of Parenting Efficacy Expectations During the Transition to Parenthood

Research demonstrates that belief in one’s effectiveness as a parent (parenting efficacy) is linked to numerous positive outcomes for new parents. Conversely, the perceived inability to meet expectations is associated with negative mental health consequences for mothers and fathers. In the present paper we examine the impact of parenting efficacy expectations on the mental health statuses of new parents. Using three waves of data spanning from the prenatal period to the 4-months postpartum period from a sample of 150 first-time mothers and fathers in the Midwestern United States, we find that parenting efficacy is negatively associated with postpartum depression (PPD) for both mothers and fathers throughout the transition period. We also find that mothers and fathers whose parenting efficacy experiences were more negative than expected reported higher levels of PPD at 1-month postpartum. This effect dissipates for mothers, but not fathers, by 4-months postpartum, suggesting differences in the experiences of mothers and fathers during this transition. We conclude that research on the transition to parenthood should continue to include fathers in an effort to better understand the mental health consequences of becoming a parent for the first time, as well as enhance interventions designed to assist couples experiencing this important transition.     

Effects of Participant’s Choice of Different Digital Interventions on Outcomes for Binge-Spectrum Eating Disorders: A Pilot Doubly Randomized Preference Trial

It is unclear whether offering individuals a choice between different digital intervention programs affects treatment outcomes. To generate initial insights, we conducted a pilot doubly randomized preference trial to test whether offering individuals with binge-spectrum eating disorder a choice between two digital interventions is causally linked with superior outcomes than random assignment to these interventions. Participants with recurrent binge eating were randomized to either a choice (n = 77) or no-choice (n = 78) group. Those in the choice group could choose one of the two digital programs, while those in the no-choice group were assigned a program at random. The two digital interventions (a broad and a focused program) took 4 weeks to complete, were based on cognitive-behavioral principles and have demonstrated comparable efficacy, but differ in scope, content, and targeted change mechanisms. Most participants (79%) allocated to the choice condition chose the broad program. While both groups experienced improvements in primary (Eating Disorder Examination Questionnaire global scores and number of binge eating episodes over the past month) and secondary outcomes (dietary restraint, body image concerns, etc.), no significant between-group differences were observed. The two groups did not differ on dropout rates, nor on most indices of intervention engagement. Findings provide preliminary insights towards the role of client preferences in digital mental health interventions for eating disorders. Client preferences may not determine outcomes when digital interventions are based on similar underlying principles, although larger trials are needed to confirm this.     

Conducting a Pragmatic Trial in Integrated Primary Care: Key Decision Points and Considerations

Pragmatic trials testing the effectiveness of interventions under “real world” conditions help bridge the research-to-practice gap. Such trial designs are optimal for studying the impact of implementation efforts, such as the effectiveness of integrated behavioral health clinicians in primary care settings. Formal pragmatic trials conducted in integrated primary care settings are uncommon, making it difficult for researchers to anticipate the potential pitfalls associated with balancing scientific rigor with the demands of routine clinical practice. This paper is based on our experience conducting the first phase of a large, multisite, pragmatic clinical trial evaluating the implementation and effectiveness of behavioral health consultants treating patients with chronic pain using a manualized intervention, brief cognitive behavioral therapy for chronic pain (BCBT-CP). The paper highlights key choice points using the PRagmatic-Explanatory Continuum Indicator Summary (PRECIS-2) tool. We discuss the dilemmas of pragmatic research that we faced and offer recommendations for aspiring integrated primary care pragmatic trialists.

     

Moving From Efficacy to Effectiveness in Eating Disorders Prevention: The Sorority Body Image Program

Although eating disorders prevention research has begun to produce programs with demonstrated efficacy, many such programs simply target individuals as opposed to engaging broader social systems (e.g., schools, sororities, athletic teams) as participant collaborators in eating disorders prevention. Yet, social systems ultimately will be responsible for the real-world delivery of eating disorder prevention programs, suggesting that an important issue has yet to be addressed. Namely, it is unclear to what degree efficacious individual-focused eating disorder prevention programs remain effective when incorporated into critical social systems under real-world conditions. Over the past 5 years, we have collaborated with the campus sororities in the development of a sustainable eating disorders prevention program that is based on the prevention efficacy literature. This paper describes both challenges and helpful strategies that we encountered in tailoring an evidence-based eating disorders prevention program to the needs of a relevant social system.