The Rapid Recovery Progression Measure: A Brief Assessment of Biopsychosocial Functioning During Substance Use Disorder Recovery.

BACKGROUND: There is debate in the literature around how to measure outcomes in treatment and recovery from substance use disorder (SUD). Various constructs have been suggested as appropriate including "recovery capital" and "treatment progression."  To contribute to this debate, the construct of "recovery progression"  has been suggested by the authors, and a psychometric assessment, the Recovery Progression Measure (RPM). Although published psychometrics data have demonstrated the RPM to be reliable, at 36-item long, it may be too lengthy to complete in clinic environments. Therefore, a shorter version has been developed, the Rapid RPM. OBJECTIVES: To examine reliability, validity, sensitivity and specificity of the Rapid RPM via data from 9208 service users. METHODS: Data were collected from service users accessing the Breaking Free Online (BFO) treatment and recovery program, which has within its baseline assessment the six-item, 11-point Likert scale Rapid RPM. Psychometric properties were examined. RESULTS: Internal reliability of the Rapid RPM was excellent, α =.92. The Rapid RPM also had good concurrent and predictive validity, with baseline scores, and changes in scores to follow-up, being significantly associated with scores on standardized measures of common mental health sequela, severity of substance dependence and quality of life, and changes in self-reported substance use. The Rapid RPM was also able to differentiate between participants scoring above thresholds on these measures for clinically relevant substance dependence and mental health difficulties. CONCLUSIONS: This study provides data to support reliability, validity, sensitivity and specificity of the Rapid RPM, indicating potential as a clinical tool.

Applying Behavior Change Theories and Qualitative Methods in Substance Misuse Implementation Research: Conceptualizing the Adoption of Breaking Free Online in Real-World Clinical Practice.

There is insufficient research examining the implementation of complex novel interventions within health care. This may be due to a lack of qualitative research providing subjective insights into these implementation processes. The authors investigate the advantages of applying behavior change theories to conceptualize qualitative data describing the processes of implementation of complex interventions. Breaking Free Online (BFO), a digital treatment intervention for substance misuse, is described as an example of a complex intervention. The authors review previous qualitative research which explored initial diffusion, or spread, of the BFO program, and its subsequent normalization as part of standard treatment for substance misuse within the health and social care charity, "Change, Grow, Live" (CGL). The use of behavior change models to structure qualitative interview findings enabled identification of facilitators and barriers to the use of BFO within CGL. These findings have implications for the development of implementation research in novel health care interventions.

Initial Development and Psychometric Properties of a New Measure of Substance Use Disorder "Recovery Progression": The Recovery Progression Measure (RPM).

UNLABELLED: There is a growing literature around substance use disorder treatment outcomes measures. Various constructs have been suggested as being appropriate for measuring recovery outcomes, including "recovery capital" and "treatment progression." However, these previously proposed constructs do not measure changes in psychosocial functioning during the recovery process. Therefore, a new psychometric assessment, the "Recovery Progression Measure" (RPM), has been developed to measure this recovery oriented psychosocial change. AIMS: The aims of this study were to evaluate the reliability and factor structure of the RPM via data collected from 2218 service users being treated for their substance dependence. METHOD: Data were collected from service users accessing the Breaking Free Online (BFO) substance use disorder treatment and recovery program, which has within its baseline assessment a 36-item psychometric measure previously developed by the authors to assess the six areas of functioning described in the RPM. Reliability analyses and exploratory factor analyses (EFA) were conducted to examine the underlying factor structure of the RPM measure. RESULTS: Internal reliability of the RPM measure was found to be excellent (α > .70) with the overall assessment to have reliability α = .89, with item-total correlations revealing moderate-excellent reliability of individual items. EFA revealed the RPM to contain an underlying factor structure of eight components. DISCUSSION: This study provides initial data to support the reliability of the RPM as a recovery measure. Further work is now underway to extend these findings, including convergent and predictive validity analyses.

Primary school-based behavioural interventions for preventing caries.

BACKGROUND: Dental caries is one of the most common global childhood diseases and is, for the most part, entirely preventable. Good oral health is dependent on the establishment of the key behaviours of toothbrushing with fluoride toothpaste and controlling sugar snacking. Primary schools provide a potential setting in which these behavioural interventions can support children to develop independent and habitual healthy behaviours. OBJECTIVES: To assess the clinical effects of school-based interventions aimed at changing behaviour related to toothbrushing habits and the frequency of consumption of cariogenic food and drink in children (4 to 12 year olds) for caries prevention. SEARCH METHODS: We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 18 October 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4), MEDLINE via OVID (1948 to 18 October 2012), EMBASE via OVID (1980 to 18 October 2012), CINAHL via EBSCO (1981 to 18 October 2012) and PsycINFO via OVID (1950 to 18 October 2012). Ongoing trials were searched for using Current Controlled Trials (to 18 October 2012) and ClinicalTrials.gov (to 18 October 2012). Conference proceedings were searched for using ZETOC (1993 to 18 October 2012) and Web of Science (1990 to 18 October 2012). We searched for thesis abstracts using the Proquest Dissertations and Theses database (1950 to 18 October 2012). There were no restrictions regarding language or date of publication. Non-English language papers were included and translated in full by native speakers. SELECTION CRITERIA: Randomised controlled trials of behavioural interventions in primary schools (children aged 4 to 12 years at baseline) were selected. Included studies had to include behavioural interventions addressing both toothbrushing and consumption of cariogenic foods or drinks and have a primary school as a focus for delivery of the intervention. DATA COLLECTION AND ANALYSIS: Two pairs of review authors independently extracted data related to methods, participants, intervention design including behaviour change techniques (BCTs) utilised, outcome measures and risk of bias. Relevant statistical information was assessed by a statistician subsequently. All included studies contact authors were emailed for copies of intervention materials. Additionally, three attempts were made to contact study authors to clarify missing information. MAIN RESULTS: We included four studies involving 2302 children. One study was at unclear risk of bias and three were at high risk of bias. Included studies reported heterogeneity in both the intervention design and outcome measures used; this made statistical comparison difficult. Additionally this review is limited by poor reporting of intervention procedure and design. Several BCTs were identified in the trials: these included information around the consequences of twice daily brushing and controlling sugar snacking; information on consequences of adverse behaviour and instruction and demonstration regarding skill development of relevant oral health behaviours.Only one included study reported the primary outcome of development of caries. This small study at unclear risk of bias showed a prevented fraction of 0.65 (95% confidence interval (CI) 0.12 to 1.18) in the intervention group. However, as this is based on a single study, this finding should be interpreted with caution.Although no meta-analysis was performed with respect to plaque outcomes (due to differences in plaque reporting between studies), the three studies which reported plaque outcomes all found a statistically significant reduction in plaque in the intervention groups with respect to plaque outcomes. Two of these trials involved an 'active' home component where parents were given tasks relating to the school oral health programme (games and homework) to complete with their children. Secondary outcome measures from one study reported that the intervention had a positive impact upon children's oral health knowledge. AUTHORS' CONCLUSIONS: Currently, there is insufficient evidence for the efficacy of primary school-based behavioural interventions for reducing caries. There is limited evidence for the effectiveness of these interventions on plaque outcomes and on children's oral health knowledge acquisition. None of the included interventions were reported as being based on or derived from behavioural theory. There is a need for further high quality research to utilise theory in the design and evaluation of interventions for changing oral health related behaviours in children and their parents.

Neuropsychological function in children following admission to paediatric intensive care: a pilot investigation.

OBJECTIVE: Little is known about neuropsychological status following acute severe paediatric illness. This pilot study explored the effects on memory function of severe acute paediatric illness and associations between memory functioning and psychiatric sequelae. DESIGN AND SETTING: Case control study of children after paediatric intensive care unit (PICU) discharge and healthy volunteers. PATIENTS AND PARTICIPANTS: 16 PICU discharged children comprised of 11 boys and 5 girls (mean age 9.44 +/- 2.85 years) tested a mean of 4.8 +/- 1.4 months following hospital discharge, and 16 age- and sex-matched controls. MEASUREMENTS AND RESULTS: Visual-spatial memory and attention were assessed using the CANTAB battery (visual memory) and verbal memory with the Children Memory Scale; Intelligence Quotient was tested using the Wechsler Abbreviated Scale of Intelligence. Emotional and behavioural function was measured with the Strengths and Difficulties Questionnaire and Impact of Event Scales. Children admitted to PICU displayed statistically poorer performance on tests of spatial memory (spatial working memory) sustained attention (rapid visual information) and verbal memory (word pairs learning and delayed recognition). Septic illness was specifically associated with poorer pattern recognition memory on the CANTAB. There were significant correlations in the PICU group between cognitive functioning and emotional/behaviour scores. CONCLUSIONS: Our results suggest impaired memory and attention in children following acute severe paediatric illness, a specific deficit in children with septic illness and links between memory anomalies and emotional/behavioural problems. The findings and their clinical significance require replication and clarification in a larger sample.

A Mixed-Methods Study Using a Nonclinical Sample to Measure Feasibility of Ostrich Community: A Web-Based Cognitive Behavioral Therapy Program for Individuals With Debt and Associated Stress.

BACKGROUND: There are increasing concerns about the health and well-being of individuals facing financial troubles. For instance, in the United Kingdom, the relationship between debt and mental health difficulties is becoming more evident due to the economic downturn and welfare reform. Access to debt counseling services is limited and individuals may be reluctant to access services due to stigma. In addition, most of these services may not be appropriately resourced to address the psychological impact of debt. This study describes outcomes from an Internet-based cognitive behavioral therapy (ICBT) program, Ostrich Community (OC), which was developed to provide support to those struggling with debt and associated psychological distress. OBJECTIVE: The aim of this feasibility study was to assess the suitability and acceptability of the OC program in a nonclinical sample and examine mental health and well-being outcomes from using the program. METHODS: A total of 15 participants (who were not suffering from severe financial difficulty) were assisted in working through the 8-week ICBT program. Participants rated usability and satisfaction with the program, and after completion 7 participants took part in a semistructured interview to provide further feedback. Before the first session and after the final session all participants completed questionnaires to measure well-being and levels of depression, stress, and anxiety and pre- and postscores were compared. RESULTS: Satisfaction was high and themes emerging from the interviews indicate that the program has the potential to promote effective financial behaviors and improve financial and global psychosocial well-being. When postcompletion scores were compared with those taken before the program, significant improvements were identified on psychometric measures of well-being, stress, and anxiety. CONCLUSIONS: The OC program is the first ICBT program that targets poor mental health associated with financial difficulty. This feasibility study indicates that OC may be an effective intervention for increasing financial resilience, supporting individuals to become financially independent, and promoting positive financial and global well-being. Further work with individuals suffering from debt and associated emotional difficulties will help to examine clinical effectiveness more closely.

Examining effectiveness of tailorable computer-assisted therapy programmes for substance misuse: Programme usage and clinical outcomes data from Breaking Free Online.

RATIONALE: When evaluating complex, tailorable digital behavioural interventions, additional approaches may be required alongside established methodologies such as randomised controlled trials (RCTs). Research evaluating a computer-assisted therapy (CAT) programme for substance misuse, Breaking Free Online (BFO), is informed by Medical Research Council (MRC) guidance recommending examination of 'mechanisms of action' of individual intervention strategies, which is relevant when evaluating digital interventions with content that may evolve over time. AIMS: To report findings from examination of mechanisms of action of tailoring advice within the BFO programme and outcomes from specific intervention strategies. METHODOLOGY: Analysis of covariance and linear regressions were used to assess intervention completion data, and psychometric and clinical outcomes, for 2311 service users accessing drug and alcohol treatment services across the UK. RESULTS: Tailoring advice provided to users appeared to prompt them to prioritise completion of intervention strategies associated with their areas of highest biopsychosocial impairment. Completion of specific intervention strategies within BFO were associated with specific clinical outcomes, with a dose response also being found. Mechanisms of action analyses revealed the primacy of cognitions, with cognitive restructuring strategies being associated with improvements in mental health, severity of substance dependence, quality of life and global biopsychosocial functioning. CONCLUSIONS: The MRC framework provides an evolved research paradigm within the field of digital behavioural change. By assessing baseline profiles of need, BFO can target the most appropriate clinical content for individual users. Mechanisms of action research can be used to inform modifications to BFO to continually update clinical content and the technology platform.

A Qualitative Study Investigating the Continued Adoption of Breaking Free Online Across a National Substance Misuse Organisation: Theoretical Conceptualisation of Staff Perceptions.

There is evidence for the effectiveness of computer-assisted therapies (CAT) in healthcare; however, implementing CAT can be challenging due to new technologies being perceived as 'disruptive'. This study used normalisation process theory (NPT) to investigate how Breaking Free Online (BFO), a treatment programme for substance misuse, is embedded as normal practice within Crime Reduction Initiatives (CRI), a health and social care charity. Interviews were conducted with CRI staff regarding their perceptions of the normalisation of BFO. Thematic analyses were used and findings structured around NPT. Results suggest that staff understood the benefits of BFO, particularly for those with a dual diagnosis. However, there was some confusion surrounding job roles and difficulties with the availability of resources. Whilst normalisation of BFO is progressing within CRI, there are still some challenges. Clarification of the roles of staff and peer mentors is an area in which further work is being conducted.

Feasibility of a UK community-based, eTherapy mental health service in Greater Manchester: repeated-measures and between-groups study of 'Living Life to the Full Interactive', 'Sleepio' and 'Breaking Free Online' at 'Self Help Services'.

OBJECTIVES: There is increasing evidence to support the effectiveness of eTherapies for mental health, although limited data have been reported from community-based services. Therefore, this service evaluation reports on feasibility and outcomes from an eTherapy mental health service. SETTING: 'Self Help Services', an Increasing Access to Psychological Therapies (IAPT) eTherapy service in Greater Manchester. PARTICIPANTS: 1068 service users referred to the service for secondary care for their mental health difficulties. INTERVENTIONS: Participants were triaged into one of three eTherapy programmes: 'Living Life to the Full Interactive' for low mood, stress and anxiety; 'Sleepio' for insomnia; and 'Breaking Free Online' for substance misuse, depending on clinical need. PRIMARY OUTCOMES MEASURES: Standardised psychometric assessments of depression, anxiety and social functioning, collected as part of the IAPT Minimum Data Set, were conducted at baseline and post-treatment. RESULTS: Data indicated baseline differences, with the Breaking Free Online group having higher scores for depression and anxiety than the Living Life to the Full Interactive (depression CI 1.27 to 3.21, p<0.0001; anxiety CI 077 to 1.72, p<0.0001) and Sleepio (depression CI 1.19 to 4.52, p<0.0001; anxiety CI 2.16 to 5.23, p<0.0001) groups. Promising improvements in mental health scores were found within all three groups (all p<0.0001), as were significant reductions in numbers of service users reaching clinical threshold scores for mental health difficulties (p<0.0001). Number of days of engagement was not related to change from baseline for the Living Life to the Full or Sleepio programmes but was associated with degree of change for Breaking Free Online. CONCLUSION: Data presented provide evidence for feasibility of this eTherapy delivery model in supporting service users with a range of mental health difficulties and suggest that eTherapies may be a useful addition to treatment offering in community-based services.

Using the Behavior Change Technique Taxonomy v1 to conceptualize the clinical content of Breaking Free Online: a computer-assisted therapy program for substance use disorders.

BACKGROUND: In recent years, research within the field of health psychology has made significant progress in terms of advancing and standardizing the science of developing, evaluating and reporting complex behavioral change interventions. A major part of this work has involved the development of an evidence-based Behavior Change Technique Taxonomy v1 (BCTTv1), as a means of describing the active components contained within such complex interventions. To date, however, this standardized approach derived from health psychology research has not been applied to the development of complex interventions for the treatment of substance use disorders (SUD). Therefore, this paper uses Breaking Free Online (BFO), a computer-assisted therapy program for SUD, as an example of how the clinical techniques contained within such an intervention might be mapped onto the BCTTv1. METHOD: The developers of BFO were able to produce a full list of the clinical techniques contained within BFO. Exploratory mapping of the BCTTv1 onto the clinical content of the BFO program was conducted separately by the authors of the paper. This included the developers of the BFO program and psychology professionals working within the SUD field. These coded techniques were reviewed by the authors and any discrepancies in the coding were discussed between all authors until an agreement was reached. RESULTS: The BCTTv1 was mapped onto the clinical content of the BFO program. At least one behavioral change technique was found in 12 out of 16 grouping categories within the BCTTv1. A total of 26 out of 93 behavior change techniques were identified across the clinical content of the program. CONCLUSION: This exploratory mapping exercise has identified the specific behavior change techniques contained within BFO, and has provided a means of describing these techniques in a standardized way using the BCTTv1 terminology. It has also provided an opportunity for the BCTTv1 mapping process to be reported to the wider SUD treatment community, as it may have real utility in the development and evaluation of other psychosocial and behavioral change interventions within this field.

Effectiveness of Computer-Assisted Therapy for Substance Dependence Using Breaking Free Online: Subgroup Analyses of a Heterogeneous Sample of Service Users.

BACKGROUND: Substance misuse services within the United Kingdom have traditionally been oriented to opiate and crack users, and attended predominantly by male service users. Groups who do not fit this demographic, such as women or those whose primary drug of choice is neither heroin nor crack, have tended to be underrepresented in services. In addition, there can be stigma associated with traditional opiate and crack-centric services. Therefore, the computerized treatment and recovery program, Breaking Free Online (BFO), was developed to enable service users to access confidential support for dependence on a wide range of substances. BFO is delivered as computer-assisted therapy (CAT), or, where appropriate, used as self-help. OBJECTIVE: The aim of this study was to report psychometric outcomes data from 393 service users accessing online support for substance misuse via BFO. METHODS: Following initial referral to substance misuse services, all participants were supported in setting up a BFO login by a practitioner or peer mentor, and, where required, assisted as they completed an online baseline assessment battery contained within the BFO program. Following a period of engagement with BFO, all participants completed the same battery of assessments, and changes in the scores on these assessments were examined. RESULTS: Significant improvements were found across the 393 service users in several areas of psychosocial functioning, including quality of life, severity of alcohol and drug dependence, depression, and anxiety (P=<.001 across all aspects of functioning). Additionally, significant improvements were found within specific subgroups of participants, including females (P=.001-<.001), males (P=.004-<.001), service users reporting alcohol dependence (P=.002-<.001), opiate and crack dependence (P=.014-<.001), and those seeking support for other substances that may be less well represented in the substance misuse sector (P=.001-<.001). CONCLUSIONS: Data from this study indicates that BFO is an effective clinical treatment for a wide range of individuals requiring support for substance misuse. Further work is currently underway to examine more closely the clinical effectiveness of the program.

The role of lifestyle in perpetuating substance use disorder: the Lifestyle Balance Model.

Conceptualizing aetiology underpinning an individual's substance use disorder (SUD) not only facilitates insight and understanding, but also serves to identify targets for treatment and aid practitioners in selecting the most appropriate interventions. There is now a wealth of literature on aetiology and treatment approaches, and in more recent years, also literature to support the concept of 'recovery' from a condition which was previously thought of as a chronic, relapsing condition. The burgeoning literature around research into recovery is revealing how recovery can best be defined and what factors might be associated with recovery from SUD. To add further to this growing body of literature, a new six-domain, explanatory biopsychosocial model of substance dependence and recovery, the Lifestyle Balance Model (LBM) is proposed. Based on research findings and theory reported in the literature, the LBM is a generic model depicting six domains of biopsychosocial functioning and includes within it the role of lifestyle. The LBM has been constructed as a domain model, allowing conceptualisation of the relationships between the six domain areas that perpetuate dependence and may also be associated with recovery from SUD, providing service users and clinicians with a tool for the delivery of case formulation and identification of target areas for intervention.

Maternally perceived barriers to and facilitators of establishing and maintaining tooth-brushing routines with infants and preschoolers.

Establishing effective toothbrushing routines using fluoridated toothpaste in infancy has been suggested as important to dental health throughout childhood and into adulthood. However, previous studies have revealed a number of potential barriers to, and facilitators of caregivers ability to establish early dyadic toothbrushing routines with pre-schoolers. However, as yet no qualitative research has been conducted to ascertain potential barriers and facilitators of the earliest dyadic toothbrushing in infancy, and nor has any previous research specifically focused on how novice mothers of first-born infants and preschoolers manage this task. This study therefore outlines findings from a qualitative interview study with first-time mothers of children aged 24-30 months (n = 16) exploring perceived barriers to and facilitators of early dyadic toothbrushing routines with infants and preschoolers. A number of key themes were identified from interview transcripts and an 'ecological' approach conceptualised maternally perceived barriers to and facilitators of dyadic toothbrushing. Proximal influences were found to be located within the caregiver-child relationship ('micro-system'), including parental cognitions (e.g., PSE), parental behaviours (e.g., parenting practices) and infant and preschooler temperament and behaviours (e.g., tantrums). Distal factors were also identified as relevant to the establishment and maintenance of these routines, such as social support ('exosystem') and family history of tooth-brushing ('chronosystem').

Health and social outcomes in adults with Williams syndrome: findings from cross-sectional and longitudinal cohorts.

Previous studies have investigated trajectories of cognitive, language and adaptive functioning in Williams syndrome (WS) but little is known about how other aspects of the Williams syndrome behavioural phenotype change across the life-span. Therefore, the present study examined age associated changes in a number of different domains of functioning in adults with WS. Semi-structured interviews and standardized assessments of physical health, educational and occupational levels, self-care and independence, social interactions, and behavioural difficulties were conducted with adults with WS and their parents/carers. Ninety-two individuals with genetic confirmation of WS (50 males, 42 females) participated in a cross-sectional study (age range 19-55 years; mean 32 years) and 43 individuals (21 males, 22 females) were involved in a longitudinal study as they had taken part in a previous study of adults with WS. Not all individuals in the longitudinal cohort had genetically confirmed WS. Cross-sectional analyses revealed no age related differences in the areas of functioning investigated. However, in the longitudinal sample, significant improvements were reported in physical health, self-care and occupational skills. Social skills and adaptive behaviours had generally improved while behavioural difficulties had declined. In both cross-sectional and longitudinal cohorts there were significant correlations between adaptive functioning and IQ. These findings are consistent in indicating no age related decline in social or adaptive functioning in adults with WS, at least up to the age of 50-55 years.

Mental health problems in adults with Williams syndrome.

Although many researchers have investigated emotional and behavioral difficulties in individuals with Williams syndrome, few have used standardized diagnostic assessments. We examined mental health problems in 92 adults with Williams syndrome using the Psychiatric Assessment Schedule for Adults with Developmental Disabilities-PAS-ADD (Moss, Goldberg, et al., 1996). Factors potentially associated with mental health problems were also explored. The PAS-ADD identified mental health problems in 24% of the sample. The most common were anxiety (16.5%) and specific phobias (12%). Other diagnoses included depression, agoraphobia, and social phobia. No association was found between the presence of mental health problems and either individual (e.g., age, IQ, language level) or external (life events) variables.