Examining the factor structure, reliability, and validity of the main outcome measure used in mentalization-based therapy skills training.

BACKGROUND AND AIMS: Multiple national guidelines stress the importance for clinicians to possess good therapeutic skills for working with patients with significant relational difficulties (who may receive a diagnosis of personality disorder). Training clinicians in mentalization-based treatment skills (MBT-S) is one approach to address this. The main outcome measure used in MBT-S studies is the Knowledge and Application of MBT Questionnaire (KAMQ). However, an absence of research into the properties and validity of the KAMQ has limited the methodological quality of MBT-S evaluations so far. The aim of this study was therefore to investigate the factor structure, internal consistency, reliability, and validity of the KAMQ. METHODS: Using an existing multiprofessional sample of 217 clinicians from 2014 to 2016, we undertook exploratory factor analysis to determine the factor structure and internal consistency of the KAMQ. Convergent validity of the measure with the Attitudes to Personality Disorder Questionnaire (APDQ) was assessed in a subset of this dataset where both questionnaires had been administered (n = 92). Additionally, by recruiting a new sample of 70 clinicians, we assessed the measure's test-retest reliability. RESULTS: Factor analysis found three factors underlying 17 of the 20 KAMQ items, relating to therapeutic skills in mentalizing, beliefs about applying MBT in practice, and specific MBT knowledge. The KAMQ was revised following the factor analysis to form the KAMQ-2 with 17 items. Internal consistency (α = .85, 95% confidence interval [CI] = 0.80-0.89) and test-retest reliability (ICC = 0.84, 95% CI = 0.73-0.91) were good. In correlation analyses, the KAMQ-2 showed convergent validity with the main factor from the APDQ (n = 48; r s = 0.39, P < .01). CONCLUSION: The KAMQ-2 provides a short, reliable self-report instrument which probes clinicians' knowledge about mentalizing skills, and beliefs about using these. There was preliminary evidence for validity. The properties of the KAMQ-2 mean that more robust evaluation and development of MBT-S is now possible.

Balint-style reflective practice groups in a year 4 undergraduate general practice attachment: experience of the first two years.

BACKGROUND AND AIMS: Many undergraduate medical curricula include reflective practice sessions based on traditional Balint-groups. Those sessions can help students to acknowledge that experiencing 'negative' feelings in relation to patients is normal and may contain important information about the clinical encounter. They may also help to protect students from some of the emotional challenges of studying medicine. The Edinburgh University scheme provides all students in their first clinical year with two dedicated reflective practice sessions. Here we report on experience of the first two years. METHODS: Students' attitudes to the sessions were ascertained using a questionnaire, and views of the group leaders were assessed using a questionnaire and through informal verbal and email discussions. Practical difficulties were recorded as they arose. RESULTS: Students generally rated the sessions positively with regard to exploring relationships and self-reflection, and they found the sessions interesting and helpful. The sessions did not seem to affect career choice. The free-text comments suggested four positive themes and four areas for future modification. CONCLUSION: We have succeeded in providing all undergraduate students with an opportunity to take part in a reflective practice. We have highlighted aspects which have been successful and suggested future improvements.

A pilot before-and-after study of a brief teaching programme for psychiatry trainees in mentalizing skills.

BACKGROUND AND AIMS: Negative attitudes in clinicians towards people with personality disorder are common and associated with poor care. National guidelines recommend developing interventions to improve attitudes. Mentalization-based treatment theory and techniques provide a plausible intervention. We therefore evaluated the effect of teaching mentalizing skills on clinicians' attitudes towards personality disorder. METHODS: Pilot before-and-after study of trainee psychiatrists receiving four teaching sessions in mentalizing skills. Self-report questionnaires were completed at baseline and post teaching programme. MAIN OUTCOME MEASURE: Attitudes to Personality Disorder Questionnaire. SECONDARY MEASURE: Knowledge and Application of Mentalization-based treatment Questionnaire. RESULTS: Sixteen doctors were recruited with no study drop-out. Mean Attitudes to Personality Disorder Questionnaire score was superior post teaching programme versus baseline (135.3 vs. 124.5, standardised mean difference = 0.72, 95% confidence interval = 0.01 to 1.44). Mean Knowledge and Application of Mentalization-based treatment Questionnaire score was superior post teaching programme versus baseline (112.5 vs. 97.1, standardised mean difference = 1.83, 95% confidence interval 0.98 to 2.67). CONCLUSIONS: As expected from a pilot study, the estimate of effect is imprecise. Within this limitation, our findings suggest that teaching in mentalizing skills improved attitudes and mentalization-based treatment knowledge to a clinically relevant degree. This has important implications for patient outcomes and staff development. Our study paves the way for a full-scale study to provide more precise and robust evidence.

Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke.

BACKGROUND: Children's exposure to other people's cigarette smoke (environmental tobacco smoke, or ETS) is associated with a range of adverse health outcomes for children. Parental smoking is a common source of children's exposure to ETS. Older children are also at risk of exposure to ETS in child care or educational settings. Preventing exposure to cigarette smoke in infancy and childhood has significant potential to improve children's health worldwide. OBJECTIVES: To determine the effectiveness of interventions aiming to reduce exposure of children to ETS. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialized Register and conducted additional searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, EMBASE, CINAHL, ERIC, and The Social Science Citation Index & Science Citation Index (Web of Knowledge). Date of the most recent search: September 2013. SELECTION CRITERIA: Controlled trials with or without random allocation. Interventions must have addressed participants (parents and other family members, child care workers and teachers) involved with the care and education of infants and young children (aged 0 to 12 years). All mechanisms for reduction of children's ETS exposure, and smoking prevention, cessation, and control programmes were included. These include health promotion, social-behavioural therapies, technology, education, and clinical interventions. DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies and extracted data. Due to heterogeneity of methodologies and outcome measures, no summary measures were possible and results were synthesised narratively. MAIN RESULTS: Fifty-seven studies met the inclusion criteria. Seven studies were judged to be at low risk of bias, 27 studies were judged to have unclear overall risk of bias and 23 studies were judged to have high risk of bias. Seven interventions were targeted at populations or community settings, 23 studies were conducted in the 'well child' healthcare setting and 24 in the 'ill child' healthcare setting. Two further studies conducted in paediatric clinics did not make clear whether the visits were to well or ill children, and another included both well and ill child visits. Thirty-six studies were from North America, 14 were in other high income countries and seven studies were from low- or middle-income countries. In only 14 of the 57 studies was there a statistically significant intervention effect for child ETS exposure reduction. Of these 14 studies, six used objective measures of children's ETS exposure. Eight of the studies had a high risk of bias, four had unclear risk of bias and two had a low risk of bias. The studies showing a significant effect used a range of interventions: seven used intensive counselling or motivational interviewing; a further study used telephone counselling; one used a school-based strategy; one used picture books; two used educational home visits; one used brief intervention and one study did not describe the intervention. Of the 42 studies that did not show a significant reduction in child ETS exposure, 14 used more intensive counselling or motivational interviewing, nine used brief advice or counselling, six used feedback of a biological measure of children's ETS exposure, one used feedback of maternal cotinine, two used telephone smoking cessation advice or support, eight used educational home visits, one used group sessions, one used an information kit and letter, one used a booklet and no smoking sign, and one used a school-based policy and health promotion. In 32 of the 57 studies, there was reduction of ETS exposure for children in the study irrespective of assignment to intervention and comparison groups. One study did not aim to reduce children's tobacco smoke exposure, but rather aimed to reduce symptoms of asthma, and found a significant reduction in symptoms in the group exposed to motivational interviewing. We found little evidence of difference in effectiveness of interventions between the well infant, child respiratory illness, and other child illness settings as contexts for parental smoking cessation interventions. AUTHORS' CONCLUSIONS: While brief counselling interventions have been identified as successful for adults when delivered by physicians, this cannot be extrapolated to adults as parents in child health settings. Although several interventions, including parental education and counselling programmes, have been used to try to reduce children's tobacco smoke exposure, their effectiveness has not been clearly demonstrated. The review was unable to determine if any one intervention reduced parental smoking and child exposure more effectively than others, although seven studies were identified that reported motivational interviewing or intensive counselling provided in clinical settings was effective.

Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke.

BACKGROUND: Children's exposure to other people's cigarette smoke (environmental tobacco smoke, or ETS) is associated with a range of adverse health outcomes for children. Parental smoking is a common source of children's exposure to ETS. Preventing exposure to cigarette smoke in infancy and childhood has significant potential to improve children's health worldwide. OBJECTIVES: To determine the effectiveness of interventions aiming to reduce exposure of children to ETS. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group trials register and conducted additional searches of two health and education databases not included in this specialised register. Date of the most recent search: October 2007. SELECTION CRITERIA: Interventions tested using controlled trials with or without random allocation were included in this review if the interventions addressed participants (parents and other family members, child care workers and teachers) involved with the care and education of infants and young children (aged 0-12 years). All mechanisms for reduction of children's environmental tobacco smoke exposure, and smoking prevention, cessation, and control programmes were included. These include smoke-free policies and legislation, health promotion, social-behavioural therapies, technology, education and clinical interventions. DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies and extracted data. Due to heterogeneity of methodologies and outcomes, no summary measures were possible and results were synthesised using narrative summaries. MAIN RESULTS: Thirty-six studies met the inclusion criteria. Four interventions were targeted at populations or community settings, 16 studies were conducted in the 'well child' healthcare setting and 13 in the 'ill child' healthcare setting. Two further studies conducted in paediatric clinics do not make clear whether the visits are to well or ill children, and another includes both well and ill child visits. Nineteen of these studies are from North America and 12 in other high income countries. Five studies are from low- or middle-income countries. In 17 of the 36 studies there was reduction of ETS exposure for children in both intervention and comparison groups. In only 11 of the 36 studies was there a statistically significant intervention effect. Four of these successful studies employed intensive counselling interventions targeted to smoking parents. We found little evidence of difference in effectiveness of interventions between the well infant, child respiratory illness and other child illness settings as contexts for parental smoking cessation interventions. One successful intervention was in the school setting, targeting the ETS exposure of children from smoking fathers. AUTHORS' CONCLUSIONS: While brief counselling interventions have been identified as successful ifor adults when delivered by physicians, this cannot be extrapolated to adults as parents in child health settings. However, there is limited support for more intensive counselling interventions for parents in such contexts. There is no clear evidence of differences between the respiratory, non-respiratory ill child, well child and peripartum settings as contexts for reduction of children's ETS exposure.