Effects of the Learning Together intervention on bullying and aggression in English secondary schools (INCLUSIVE): a cluster randomised controlled trial.

BACKGROUND: Bullying, aggression, and violence among children and young people are some of the most consequential public mental health problems. We tested the Learning Together intervention, which involved students in efforts to modify their school environment using restorative practice and by developing social and emotional skills. METHODS: We did a cluster randomised trial, with economic and process evaluations, of the Learning Together intervention compared with standard practice (controls) over 3 years in secondary schools in south-east England. Learning Together consisted of staff training in restorative practice; convening and facilitating a school action group; and a student social and emotional skills curriculum. Primary outcomes were self-reported experience of bullying victimisation (Gatehouse Bullying Scale; GBS) and perpetration of aggression (Edinburgh Study of Youth Transitions and Crime (ESYTC) school misbehaviour subscale) measured at 36 months. We analysed data using intention-to-treat longitudinal mixed-effects models. This trial was registered with the ISRCTN registry (10751359). FINDINGS: We included 40 schools (20 in each group); no schools withdrew. 6667 (93·6%) of 7121 students participated at baseline and 5960 (83·3%) of 7154 at 36 months. Mean GBS bullying score at 36 months was 0·34 (SE 0·02) in the control group versus 0·29 (SE 0·02) in the intervention group, with a significant adjusted mean difference (-0·03, 95% CI -0·06 to -0·001; adjusted effect size -0·08). Mean ESYTC score at 36 months was 4·33 (SE 0·20) in the control group versus 4·04 (0·21) in the intervention group, with no evidence of a difference between groups (adjusted difference -0·13, 95% CI -0·43 to 0·18; adjusted effect size -0·03). Costs were an additional £58 per pupil in intervention schools than in control schools. INTERPRETATION: Learning Together had small but significant effects on bullying, which could be important for public health, but no effect on aggression. Interventions to promote student health by modifying the whole-school environment are likely to be one of the most feasible and efficient ways of addressing closely related risk and health outcomes in children and young people. FUNDING: National Institute for Health Research, Educational Endowment Foundation.

Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden.

Type 2 diabetes in adolescence manifests as a severe progressive form of diabetes that frequently presents with complications, responds poorly to treatment, and results in rapid progression of microvascular and macrovascular complications. Although overall still a rare disease, adolescent type 2 diabetes now poses major challenges to paediatric and adult diabetes services in many countries. Therapeutic options are heavily curtailed by a dearth of knowledge about the condition, with low numbers of participants and poor trial recruitment impeding research. Together with lifestyle modification, metformin remains the first-line therapy for adolescents with type 2 diabetes, although the majority rapidly progress to treatment failure and insulin therapy. Early bariatric surgery is controversial but has great potential to transform outcomes. Health systems must respond by both concentrating patients in specialist clinical services integrated with translational research programmes, but also by joining up with local health and social care services to improve engagement and uptake of services.

Depressive symptoms, pain and disability for adolescent patients with juvenile idiopathic arthritis: results from the Childhood Arthritis Prospective Study.

Objectives: To determine if depressive symptoms assessed near diagnosis associate with future measures of pain, disability and disease for adolescent patients diagnosed with JIA. Methods: Data were analysed from JIA patients aged 11-16 years recruited to the Childhood Arthritis Prospective Study, a UK-based inception cohort of childhood-onset arthritis. Depressive symptoms (using the Mood and Feelings Questionnaire; MFQ), active and limited joint count, disability score (Childhood Health Assessment Questionnaire), pain visual analogue scale and patient's general evaluation visual analogue scale were collected. Associations between baseline measures (first visit to paediatric rheumatologist) were analysed using multiple linear regression. Linear mixed-effect models for change in the clinical measures of disease over 48 months were estimated including MFQ as an explanatory variable. Results: Data from 102 patients were analysed. At baseline, median (IQR) age was 13.2 years (11.9-14.2 years) and 14.7% scored over the MFQ cut-off for major depressive disorder. At baseline, depressive symptoms significantly associated with all clinical measures of disease (P ⩽ 0.01). High baseline depressive symptoms scores predicted worse pain (P ⩽ 0.005) and disability (P ⩽ 0.001) 12 months later but not active and limited joint counts. Conclusions: Adolescent patients with JIA and depressive symptoms had more active joints, pain and disability at the time of their first specialist appointment. The associations between baseline depression and both pain and disability continued for at least one year, however, this was not the case for active joint count.

A clinical review of communication training for haematologists and haemato-oncologists: a case of art versus science.

The art of communication at times seems at odds with the science of medicine. Poor communication is associated with risks for patient and physician. Communication skills are highly relevant for haematologists and are associated with increased physician and patient satisfaction, positive psychosocial outcomes and possible health outcomes. Medical communication training has recently become widespread but is largely restricted to junior medical professionals. In haematology, the proliferation of high quality communication skills is low and there are few interventions catering for the required skillset. A review identified five applicable interventions for haematologists. There is variation in intervention length and structure, and most studies measure targeted skill fidelity rather than patient outcomes. Work on motivation and empowerment holds potential for haematological conditions, but is largely absent from care. This review highlights the need for new interventions for haematologists which focus on producing and maintaining positive patient outcomes.

Impact of deprivation, ethnicity, and insulin pump therapy on developmental trajectories of diabetes control in COB type 1 diabetes.

BACKGROUND: There is marked variation in diabetes outcomes for children and adolescents across the UK. We used modelling techniques to examine the independent contributions of deprivation, ethnicity, insulin pump use, and health service use on HbA1c trajectories across adolescence. METHODS: Prospective data from a large UK Paediatric & Adolescent Diabetes Service on subjects with type 1 diabetes (T1D) aged 9-17 years from January 2008 to December 2013: 2560 HbA1c datapoints were available on 384 patients [193 (50.4%) female]. Sequential multilevel growth models assessed the effects of sex, duration of diabetes, deprivation, ethnicity, insulin pump use, and health service use on HbA1c . Growth mixture models were used to identify discrete HbA1c trajectories across adolescence. RESULTS: Mean clinic HbA1c decreased from 2008 to 2013 by 0.122% (95% confidence interval: 0.034, 0.210; P = .007) per year. The optimal multilevel growth model showed mean HbA1c increased with age (B = 0.414, P < .0001), and that mean HbA1c was predicted by white/British ethnicity (B = -0.748, P = .004), clinic visits (B = 0.041, P = .04), and pump use (B = -0.568, P < .0001) but not deprivation. The optimal mixture model was a four trajectory group solution, with 45.1% in Good Control, 39.6% with Deteriorating Control, 6.5% with Rapidly Deteriorating Control, and 8.8% in Poor Control across adolescence. Only pump use predicted trajectory group membership, being protective against membership of all other trajectories compared with Good Control. CONCLUSIONS: Increasing uptake of insulin pumps and ensuring access to health services are likely to be the most effective means of reducing inequalities in outcomes of T1D in children and young people.

The transition of young adults with lifelong urological needs from pediatric to adult services: An international children's continence society position statement.

INTRODUCTION: Children with urinary tract disorders managed by teams, or individual pediatricians, urologists, nephrologists, gastroenterologists, neurologists, psychologists, and nurses at some point move from child-centered to adult-centered health systems. The actual physical change is referred to as the transfer whilst the process preceding this move constitutes transition of care. Our aims are twofold: to identify management and health-service problems related to children with congenital or acquired urological conditions who advance into adulthood and the clinical implications this has for long-term health and specialist care; and, to understand the issues facing both pediatric and adult-care clinicians and to develop a systems-approach model that meets the needs of young adults, their families and the clinicians working within adult services. METHODS: Information was gleaned from presentations at an International Children's Continence Society meeting with collaboration from the International Continence Society, that discussed problems of transfer and transitioning such children. Several specialists attending this conference finalized this document identifying issues and highlighting ways to ease this transition and transfer of care for both patients and practitioners. RESULTS: The consensus was, urological patients with congenital or other lifelong care needs, are now entering adulthood in larger numbers than previously, necessitating new planning processes for tailored transfer of management. Adult teams must become familiar with new clinical problems in multiple organ systems and anticipate issues provoked by adolescence and physical growth. During this period of transitional care the clinician or team assists young patients to build attitudes, skills and understanding of processes needed to maximize function of their urinary tract-thus taking responsibility for their own healthcare needs. Preparation must also address, negotiating adult health care systems, psychosocial, educational or vocational issues, and mental wellbeing. CONCLUSIONS: Transitioning and transfer of children with major congenital anomalies to clinicians potentially unfamiliar with their conditions requires improved education both for receiving doctors and children's families. Early initiation of the transition process should allow the transference to take place at appropriate times based on the child's development, and environmental and financial factors. Neurourol. Urodynam. 36:811-819, 2017. © 2016 Wiley Periodicals, Inc.

The role of family and school-level factors in bullying and cyberbullying: a cross-sectional study.

BACKGROUND: Bullying and cyberbullying are common phenomena in schools. These negative behaviours can have a significant impact on the health and particularly mental health of those involved in such behaviours, both as victims and as bullies. This UK study aims to investigate student-level and school-level characteristics of those who become involved in bullying and cyberbullying behaviours as victims or perpetrators. METHODS: We used data from 6667 Year 7 students from the baseline survey of a cluster randomized trial in 40 English schools to investigate the associations between individual-level and school-level variables with bullying victimization, cyberbullying perpetration, and cyberbullying victimization. We ran multilevel models to examine associations of bullying outcomes with individual-level variables and school-level variables. RESULTS: In multilevel models, at the school level, school type and school quality measures were associated with bullying risk: students in voluntary-aided schools were less likely to report bullying victimization (0.6 (0.4, 0.9) p = 0.008), and those in community (3.9 (1.5, 10.5) p = 0.007) and foundation (4.0 (1.6, 9.9) p = 0.003) schools were more likely to report being perpetrators of cyberbullying than students in mainstream academies. A school quality rating of "Good" was associated with greater reported bullying victimization (1.3 (1.02, 1.5) p = 0.03) compared to ratings of "Outstanding." CONCLUSIONS: Bullying victimization and cyberbullying prevalence vary across school type and school quality, supporting the hypothesis that organisational/management factors within the school may have an impact on students' behaviour. These findings will inform future longitudinal research investigating which school factors and processes promote or prevent bullying and cyberbullying behaviours. TRIAL REGISTRATION: Trial ID: ISRCTN10751359 Registered: 11/03/2014 (retrospectively registered).

An interpretative phenomenological analysis of the psychosexual identity development in adolescent and young adult survivors of testicular cancer.

BACKGROUND: Qualitative research has explored how some testicular cancer survivors (TCS) experience the psychological impacts of diagnosis and treatment. More research into the impacts of testicular cancer (TC) on adolescent and young adults (AYA) is needed due to the critical period of identity development. The present study aimed to explore how AYA with TC appraise and make sense of their experience and to develop a greater understanding of psychosexual identity development in AYA TCS. METHOD: Eight AYA TCS were interviewed. The results were analysed using Interpretative Phenomenological Analysis. The questions explored the experiences relating to diagnosis and treatment, how it affected their psychosexual identity development (e.g., sexual relationships and self-image) and the meanings attached to the experiences. ANALYSIS: Four Group Experiential Themes were developed from the data; 'Dealing with the shock', 'Fear and weight of responsibility', 'those closest to me' and 'sense of change'. DISCUSSION: The AYA TCS experiences may result in adoption of traditional masculine traits (e.g., stoicism) or abandonment of traditionally masculine traits (E.g. violence and aggression). AYA TCS also described feelings of insecurity when compared to other men. Psychology input could help manage stoicism and feelings of inferiority when compared to men with two testicles.

BackgroundQualitative research has explored how some testicular cancer survivors (TCS) cope with the psychological impacts of diagnosis and treatment. However, there is a need for more research on the effects of testicular cancer (TC) specifically in adolescent and young adults (AYA), given the critical period of identity development during this stage. The present study aimed to explore how AYA with TC perceive and make sense of their experiences, with a focus on psychosexual identity development.MethodEight AYA TCS were interviewed, and their responses were analyzed using Interpretative Phenomenological Analysis. The interviews covered topics related to diagnosis, treatment, and how these experiences influenced their psychosexual identity (including sexual relationships and self-image).AnalysisFour main themes emerged from the data: "Dealing with the shock": Participants discussed their initial reactions to the diagnosis. "Fear and weight of responsibility": AYA TCS grappled with fear and the burden of managing their health. "Those closest to me": Relationships with family and friends played a significant role in their experiences. "Sense of change": Participants described how their cancer journey impacted their sense of self.DiscussionAYA TCS may either adopt traditional masculine traits (such as stoicism) or abandon them (e.g., violence and aggression). Additionally, they expressed feelings of insecurity when comparing themselves to other men. Psychology support could help manage stoicism and address feelings of inferiority when compared to men with two testicles.

Parents' experiences of support during and after their child's diagnosis of meningococcal disease.

AIM: To understand parents'/carers' experiences of support received following their child's diagnosis of invasive meningococcal serogroup B disease (MenB). METHODS: Structured interviews with parents/carers of 244 survivors of MenB disease in childhood, drawn from a population-based case-control study. RESULTS: Responses indicated that optimal support should encompass the whole treatment pathway, beginning with fast and accurate recognition of MenB by clinicians, followed by the provision of information about the symptoms and possible sequelae of MenB, better communication about the treatment process and disease progression and greater follow-up care. CONCLUSION: Parents' experience of support following their child's diagnosis of MenB could be significantly enhanced through better education and enhanced knowledge in health care professionals, improved access to information about short- and long-term sequelae and easier access to follow-up support and advice. Much of the data generated pertained to situations and processes common to most serious illnesses occurring in children and therefore it is likely that these findings pose wider questions about support and communication in paediatrics.

Results of a feasibility randomised controlled trial (RCT) for WATCH IT: a programme for obese children and adolescents.

BACKGROUND: In the evaluation of childhood obesity interventions, few researchers undertake a rigorous feasibility stage in which the design and procedures of the evaluation process are examined. Consequently, phase III studies often demonstrate methodological weaknesses. PURPOSE: Our aim was to conduct a feasibility trial of the evaluation of WATCH IT, a community obesity intervention for children and adolescents. We sought to determine an achievable recruitment rate; acceptability of randomisation, assessment procedures, and dropout rate; optimal outcome measures for the definitive trial; and a robust sample size calculation. METHOD: Our goal was to recruit 70 participants over 6 months, randomise them to intervention or control group, and retain participation for 12 months. Assessments were taken prior to randomisation and after 6 and 12 months. Procedures mirrored those intended for a full-scale trial, but multiple measures of similar outcomes were included as a means to determine those most appropriate for future research. Acceptability of the research and impact of the research on the programme were ascertained through interviewing participants and staff. RESULTS: We recruited 70 participants and found that randomisation and data collection procedures were acceptable. Self-referral (via media promotion) was more effective than professional referral. Blinding of assessors was sustained to a reasonable degree, and optimal outcome measures for a full-scale trial were identified. Estimated sample size was significantly greater than sample sized reported in published trials. There was some negative impact on the existing programme as a result of the research, a lesson for designers of future trials. LIMITATIONS: We successfully recruited socially disadvantaged families, but the majority of families were of White British nationality. The composition of the participants was an added valuable lesson, suggesting that recruitment strategies to obtain a more heterogeneous ethnic sample warrant consideration in future research. CONCLUSIONS: This study provided us with confidence that we can run a phase III multi-centre trial to test the effectiveness of WATCH IT. Importantly, it was invaluable in informing the design not only of that trial but also of future evaluations of childhood obesity treatment interventions.

Long-term outcomes of pneumococcal meningitis in childhood and adolescence.

A vaccine to prevent pneumococcal meningitis (PM) has recently been introduced. However, contemporary data to inform cost-effectiveness analysis and justify its routine use are sparse. We examined the cognitive, educational, psychological and social outcomes of PM in childhood. We completed a population-based case-control study in two regions of the UK. Children and young people currently between 3 and 20 years of age that had been diagnosed with PM ≤14 years of age were identified from active regional surveillance. Controls were siblings or neighbours of similar age. Standardised questionnaires and neuropsychological testing was administered to assess IQ, educational attainments, memory, psychological distress, quality of life and hearing impairment. Data were available on 97 patients and 93 controls. Eighty-four patients had a sibling/neighbour-matched control. Both matched and unmatched analyses were completed, and results of the 84 matched comparisons were highly similar to the unmatched. For the total sample, controls were similar in age, ethnicity and socioeconomic status. Median age at meningitis was 11 months. Median time between meningitis and assessment was 6.0 years. In the matched analysis, partial or profound hearing impairment was reported in 14% of patients and 1% of controls. Patients had significantly lower mean full-scale IQ (p = 0.05), verbal IQ (p = 0.0008), numeracy (p = 0.02), total quality of life (p = 0.04), school functioning (p = 0.005), psychosocial functioning (p = 0.001) and psychological difficulties (p = 0.01). Parents of patients reported greater functional disability (p = 0.008), impairment in all aspects of quality of life (p = 0.001) and psychological difficulties (p < 0.0006). Findings for IQ were not materially different when analyses were repeated only in those without hearing impairment. In multivariate regression analysis that included both case-control status and hearing status, both being a patient (p = 0.001) and having profound hearing impairment (p = 0.001) were independently associated with lower full-scale IQ. Conclusions Pneumococcal meningitis is associated with major sequelae. Our findings strongly support the introduction of pneumococcal conjugate vaccine as part of routine childhood vaccination programmes internationally.

A qualitative investigation of selecting surrogate decision-makers.

BACKGROUND: Empirical studies of surrogate decision-making tend to assume that surrogates should make only a 'substituted judgement'--that is, judge what the patient would want if they were mentally competent. OBJECTIVES: To explore what people want in a surrogate decision-maker whom they themselves select and to test the assumption that people want their chosen surrogate to make only a substituted judgement. METHODS: 30 undergraduate students were recruited. They were presented with a hypothetical scenario about their expected loss of mental capacity in the future and asked to answer some questions about their choice of surrogate. These data were analysed qualitatively using thematic content analysis. RESULTS: Most respondents talked about choosing someone who was caring and competent in certain ways, giving interesting evidence for their judgements. Surprisingly few highlighted how well they thought their chosen surrogate knew their preferences and would be able to make a substituted judgement. Moreover, few specified that their chosen surrogate had similar attitudes and values to their own and so would make a similar decision to theirs in the circumstances presented. Some respondents also referred to the social role of their chosen surrogate or the social dynamics of their situation which influenced their choices, as well as to ideas of reciprocity and characteristics of honesty and loyalty. CONCLUSION: In the event that they lose mental capacity, many people will not select a surrogate to decide about medical treatments on their behalf solely on the basis that they expect their surrogate to make a substituted judgement.

The contribution of peer trainers to the Tree of Life project for young people living with Type 1 Diabetes: Building community.

This paper describes the involvement of peer trainers in Tree of Life groups for young people living with Type 1 Diabetes. The approach is informed by narrative therapy and collective narrative practice and principles, where people are seen as separate from problems and the focus is on creating opportunities for people to tell and witness one another's preferred identity stories. Young people who have participated in a Tree of Life day are invited to join the project as peer trainers who help facilitate, engage group participants, witness their stories and consult to the project. Involving peer trainers also aims to create a community where preferred identity stories can be lived and witnessed. This paper describes the training for peer trainers and the building of community.

Fitness enhances psychosocial well-being and self-confidence in young men with hemophilia: Results from Project GYM.

INTRODUCTION: Contemporary hemophilia care supports physical activity, its benefits being well recognized. Despite recognition of the psychological challenges encountered by people with hemophilia, little is known about the psychological impact of physical fitness in this population. AIM: To identify changes in psychological well-being in young men with hemophilia through participation in a gym program. METHODS: This observational feasibility study of a 6-month gym participation program used validated questionnaires pre- and poststudy to evaluate motivation to exercise, physical activity levels, self-efficacy, self-esteem, and quality of life. Individual audio-recorded interviews about study participation and impact were transcribed verbatim and analyzed for recurring themes using thematic analysis. RESULTS: Nineteen participants aged 18-25 years with hemophilia A or B (all severities ± inhibitor) consented to the study; two were lost to follow-up. There was a shift in motivation to exercise as shown by the Stages of Change grouping moving from contemplation to action and maintenance phases (p = 0.03). Self-efficacy overall scores showed a trend (p < 0.06) towards improvement. Median self-esteem scores improved from 22 (range 12-30, n = 19) to 25 (range 13-30, n = 17), a statistically significant change (p = 0.02). Three participants recorded scores below the accepted normal range before study, of whom two improved at study end. The key themes identified from the interviews were: fear, self-confidence, "being normal," pain, weight loss, ability, getting fitter. CONCLUSIONS: The psychological wellbeing of young men with hemophilia improved during this study. This may have been related to participating in a gym-based, physical exercise program.

Is earlier obesity associated with poorer executive functioning later in childhood? Findings from the Millennium Cohort Study.

BACKGROUND: Children affected with overweight or obesity have been associated with having lower educational achievement compared to peers who are non-overweight/obese. One of the drivers of this association could be a link between obesity and poorer executive function. Evidence is limited to small, cross-sectional studies which lack adjustment for important common causes. OBJECTIVE: We investigate the association between weight status and executive function longitudinally in mid-childhood, accounting for potential common causes. METHODS: Linear regression analyses were conducted to examine associations between weight status between 5 and 7 years and executive functioning at 11 years in members of the Millennium Cohort Study (n = 7739), accounting for a wide range of potential common causes. Age- and sex-specific International Obesity Taskforce cut-points for body mass index (BMI) were used. Executive function, including decision-making, impulsivity and spatial working memory, was assessed using the Cambridge Neuropsychological Test Automated Battery. RESULTS: There were no unadjusted associations between weight status and decision-making or impulsivity. After adjustment for all potential common causes, there was a lack of consistent evidence to support an association between persistent obesity (including overweight) between 5 and 7 years and spatial working memory task at 11 years. CONCLUSIONS: We found little evidence that poorer spatial working memory contributes to the association of children with obesity having lower educational achievement.

Keeping young people connected during COVID-19: the role of online groups.

The COVID-19 pandemic has had a profound impact on young people, disrupting education, routines, hobbies and peer interactions and there is concern for longer term effects on physical and mental health outcomes. Young people living with chronic health conditions face additional challenges including reduced or no face-to-face contact with medical teams, shielding and the increased stressors of being in 'at-risk' groups and social isolation. In a climate of social isolation and disconnectedness, online groups could provide a method of delivering healthcare and support that strengthens social connectedness and reduces isolation. Despite the technology being available, uptake and evidence for online groups is limited. This article shares learnings from a paediatric and adolescent psychology service delivering online groups for young people with chronic health conditions and their healthcare teams. Ideas for how to transfer group process to online platforms are considered, with examples and tips. With sufficient staffing, preparation, thought, creativity and innovation, it is possible for face-to-face groups to successfully be offered online. Caution should be exercised trying to run online groups without these provisions in place, as the safety, comfort and experience of young people could be jeopardised. Further research is needed to better understand group processes online and to consider what is lost and what is gained when comparing online to face-to-face groups.

What factors influence healthcare professionals to refer children and families to paediatric psychology?

OBJECTIVES: This study aimed to investigate factors influencing referral of children with physical illness to paediatric psychology. Due to high rates of mental health problems within this population, studies have shown that referral to paediatric psychology should be increased. However, few studies have examined factors shaping healthcare professionals' referral behaviour. METHODS: This study used the theory of planned behaviour to develop a questionnaire which explores factors influencing the referral of children and families to paediatric psychology. Psychometric properties of the questionnaire were examined. RESULTS: The questionnaire was found to have good reliability and validity. The main constructs of the theory of planned behaviour were useful in predicting intention to refer to paediatric psychology. Specific beliefs about referral were shown to influence intention to refer. CONCLUSION: Findings suggest that individual attitudes and beliefs can impact healthcare professionals' referral behaviour, indicating that multidisciplinary interventions and inter-professional education relating to the psychological aspects of illness are required.

Business as usual? Psychological support at a distance.

The impact of COVID-19 has challenged the long accepted 'norm' in delivery of psychological therapy. Public policies designed to reduce transmission have made it extremely difficult to meet with service-users safely in the traditional face-to-face context. E-therapies have existed in theory and practice since technological progress has made them possible. They can offer a host of advantages over face-to-face equivalents, including improved access, greater flexibility for service-users and professionals, and cost savings. However, despite the emerging evidence and anticipated positive value, implementation has been slower than anticipated. Concerns have been raised by service-users, clinicians, and public health organisations, identifying significant barriers to the wide spread use of e-therapies. In the current climate, many clinicians are offering e-therapies for the first time, without prior arrangement or training, as the only viable option to continue to support their clients. This paper offers a clinically relevant review of the e-therapies literature, including effectiveness and acceptability dilemmas and challenges that need to be addressed to support the safe use and growth of e-therapies in psychology services. Further research is needed to better understand what might be lost and what gained in comparison to face-to-face therapy, and for which client groups and settings it might be most effective.

Association of Anxiety With Pain and Disability but Not With Increased Measures of Inflammation in Adolescent Patients With Juvenile Idiopathic Arthritis.

OBJECTIVE: To explore whether anxiety and depression are associated with clinical measures of disease for adolescent patients with juvenile idiopathic arthritis (JIA) and whether anxiety and depression are associated with increased peripheral proinflammatory cytokine levels in adolescent patients with JIA and in healthy adolescent controls. METHODS: A total of 136 patients with JIA and 88 healthy controls ages 13-18 years completed questionnaires on anxiety and depressive symptoms. For patients with JIA, pain, disability, physician global assessment (using a visual analog scale [VAS]), and number of joints with active inflammation (active joint count) were recorded. In a subsample, we assessed lipopolysaccharide-stimulated interleukin 6 (IL-6) production from peripheral blood mononuclear cells, serum IL-6, cortisol, and C-reactive protein levels. Data were analyzed by linear regression analysis. RESULTS: Levels of anxiety and depressive symptoms in patients with JIA were not significantly different than those in healthy controls. For patients with JIA, anxiety was significantly associated with disability (ß = 0.009, P = 0.002), pain (ß = 0.029, P = 0.011), and physician global assessment VAS (ß = 0.019, P = 0.012), but not with active joint count (ß = 0.014, P = 0.120). Anxiety was not associated with any laboratory measures of inflammation for JIA patients. These relationships were also true for depressive symptoms. For healthy controls, there was a trend toward an association of anxiety (but not depressive symptoms) with stimulated IL-6 (ß = 0.004, P = 0.052). CONCLUSION: Adolescent patients with JIA experience equivalent levels of anxiety and depressive symptoms as healthy adolescents. For adolescent patients with JIA, anxiety and depressive symptoms are associated with pain, disability, and physician global assessment VAS, but not with inflammation.

Maximising engagement, motivation and long term change in a Structured Intensive Education Programme in Diabetes for children, young people and their families: Child and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE).

BACKGROUND: This trial aims to evaluate effective delivery and cost effectiveness of an innovative structured psycho-educational programme (CASCADE) for young people and their families living with diabetes. The increase in numbers of people being diagnosed with diabetes is posing a challenge for both the UK and the rest of the world. The peak age for diagnosis is between 10 and 14 years of age. There is clear evidence that improved diabetes control from diagnosis in childhood can reduce the incidence and progression of long-term complications. However, despite the development of improved insulin regimens and delivery methods, the overall metabolic control in children and adolescents has improved little in the UK in the past decade. Therefore there is a need for novel interventions and health delivery mechanisms aimed at young people and their families to help improve control and reduce complications, illness burden and costs to the NHS. METHODS/DESIGN: The CASCADE trial is a multi-centre randomised control trial with 26 clinics randomised to control or intervention groups, with 572 children and young people involved in the study. The intervention will be delivered in 4 group sessions, over a 4 month period. A developmentally appropriate curriculum will be delivered to groups of 3 - 4 families, focusing on achievement of increasing competency in self-management of diabetes. The control group will receive standard care from their clinical team, usually consisting of regular 3-monthly clinic visits and telephone contact as required with the clinical nurse specialist and consultant. The primary outcomes of the trial will be change in HbA1c between baseline and 12 months and 24 months post recruitment. Secondary outcomes will include measures related to the economic evaluation, psychosocial outcomes, outcomes related to management of diabetes outcomes, and adherence to the intervention. DISCUSSION: The trial will be run by independent research and service delivery teams and supervised by a trial steering committee. A data monitoring and ethics committee has been put in place to monitor the trial and recommend stopping/continuation according to a Peto-Haybittle rule. The trial will be conducted according to the principles of MRC Good Clinical Practice (GCP) Guidelines and CTRU Phase III Trial Standard Operating procedures. TRIAL REGISTRATION: Current Controlled Trials ISRCTN52537669.