Research Review: Integrated healthcare for children and young people in secondary/tertiary care - a systematic review.

BACKGROUND: Children and young people (CYP) with comorbid physical and/or mental health conditions often struggle to receive a timely diagnosis, access specialist mental health care, and more likely to report unmet healthcare needs. Integrated healthcare is an increasingly explored model to support timely access, quality of care and better outcomes for CYP with comorbid conditions. Yet, studies evaluating the effectiveness of integrated care for paediatric populations are scarce. AIM AND METHODS: This systematic review synthesises and evaluates the evidence for effectiveness and cost-effectiveness of integrated care for CYP in secondary and tertiary healthcare settings. Studies were identified through systematic searches of electronic databases: Medline, Embase, PsychINFO, Child Development and Adolescent Studies, ERIC, ASSIA and British Education Index. FINDINGS: A total of 77 papers describing 67 unique studies met inclusion criteria. The findings suggest that integrated care models, particularly system of care and care coordination, improve access and user experience of care. The results on improving clinical outcomes and acute resource utilisation are mixed, largely due to the heterogeneity of studied interventions and outcome measures used. No definitive conclusion can be drawn on cost-effectiveness since studies focused mainly on costs of service delivery. The majority of studies were rated as weak by the quality appraisal tool used. CONCLUSIONS: The evidence of on clinical effectiveness of integrated healthcare models for paediatric populations is limited and of moderate quality. Available evidence is tentatively encouraging, particularly in regard to access and user experience of care. Given the lack of specificity by medical groups, however, the precise model of integration should be undertaken on a best-practice basis taking the specific parameters and contexts of the health and care environment into account. Agreed practical definitions of integrated care and associated key terms, and cost-effectiveness evaluations are a priority for future research.

Childhood socio-economic disadvantage predicts reduced myelin growth across adolescence and young adulthood.

Socio-economic disadvantage increases exposure to life stressors. Animal research suggests early life stressors impact later neurodevelopment, including myelin developmental growth. To determine how early life disadvantage may affect myelin growth in adolescence and young adulthood, we analysed data from an accelerated longitudinal neuroimaging study measuring magnetisation transfer (MT), a myelin-sensitive marker, in 288 participants (149 female) between 14 and 25 years of age at baseline. We found that early life economic disadvantage before age 12, measured by a neighbourhood poverty index, was associated with slower myelin growth. This association was observed for magnetization transfer in cortical, subcortical and core white matter regions, and also in key subcortical nuclei. Participant IQ at baseline, alcohol use, body mass index, parental occupation and self-reported parenting quality did not account for these effects, but parental education did so partially. Specifically, positive parenting moderated the effect of socio-economic disadvantage in a protective manner. Thus, early socioeconomic disadvantage appears to alter myelin growth across adolescence. This finding has potential translational implications, including clarifying whether reducing socio-economic disadvantage during childhood, and increasing parental education and positive parenting, promote normal trajectories of brain development in economically disadvantaged contexts.

Multisystemic therapy versus management as usual in the treatment of adolescent antisocial behaviour (START): a pragmatic, randomised controlled, superiority trial.

BACKGROUND: Adolescent antisocial behaviour is a major health and social problem. Studies in the USA have shown that multisystemic therapy reduces such behaviour and the number of criminal offences committed by this group. However, findings outside the USA are equivocal. We aimed to assess the effectiveness and cost-effectiveness of multisystemic therapy versus management as usual in the treatment of adolescent antisocial behaviour. METHODS: We did an 18 month, multisite, pragmatic, randomised controlled, superiority trial in England. Eligible participants aged 11-17 years with moderate-to-severe antisocial behaviour had at least three severity criteria indicating past difficulties across several settings and one of five general inclusion criteria for antisocial behaviour. We randomly assigned families (1:1) using stochastic minimisation, stratifying for treatment centre, sex, age at enrolment to study, and age at onset of antisocial behaviour, to receive either management as usual or 3-5 months of multisystemic therapy followed by management as usual. Research assistants and investigators were masked to treatment allocation; the participants could not be masked. The primary outcome was out-of-home placement at 18 months. The primary analysis included all randomised participants for whom data were available. This trial is registered, number ISRCTN77132214. Follow-up of the trial is still ongoing. FINDINGS: Between Feb 4, 2010, and Sept 1, 2012, 1076 families were referred to nine multi-agency panels, 684 of whom were assigned to management as usual (n=342) or multisystemic therapy followed by management as usual (n=342). At 18 months, the proportion of participants in out-of-home placement was not significantly different between the groups (13% [43/340] in the multisystemic therapy group vs 11% [36/335] in the management-as-usual group; odds ratio 1·25, 95% CI 0·77-2·05; p=0·37). INTERPRETATION: The findings do not support that multisystemic therapy should be used over management as usual as the intervention of choice for adolescents with moderate-to-severe antisocial behaviour. FUNDING: Department for Children, Schools and Families, Department of Health.

Cognitive-behavioural therapy and short-term psychoanalytic psychotherapy versus brief psychosocial intervention in adolescents with unipolar major depression (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled trial.

BACKGROUND: Although there are effective psychological treatments for unipolar major depression in adolescents, whether or not one or more of the available therapies maintain reduced depressive symptoms 1 year after the end of treatment is not known. This is a non-trivial issue because maintaining lowered depressive symptoms below a clinical threshold level reduces the risk for diagnostic relapse into the adult years. OBJECTIVE: To determine whether or not either of two specialist psychological treatments, cognitive-behavioural therapy (CBT) or short-term psychoanalytic psychotherapy (STPP), is more effective than a reference brief psychosocial intervention (BPI) in maintaining reduction of depression symptoms in the year after treatment. DESIGN: Observer-blind, parallel-group, pragmatic superiority randomised controlled trial. SETTING: A total of 15 outpatient NHS clinics in the UK from East Anglia, north-west England and North London. PARTICIPANTS: Adolescents aged 11-17 years with Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition major depression including those with suicidality, depressive psychosis and conduct disorder. Patients were randomised using stochastic minimisation controlling for age, sex and self-reported depression sum score; 470 patients were randomised and 465 were included in the analyses. INTERVENTIONS: In total, 154 adolescents received CBT, 156 received STPP and 155 received BPI. The trial lasted 86 weeks and study treatments were delivered in the first 36 weeks, with 52 weeks of follow-up. MAIN OUTCOME MEASURES: Mean sum score on self-reported depressive symptoms (primary outcome) at final study assessment (nominally 86 weeks, at least 52 weeks after end of treatment). Secondary measures were change in mean sum scores on self-reported anxiety symptoms and researcher-rated Health of the Nation scales for children and adolescents measuring psychosocial function. Following baseline assessment, there were a further five planned follow-up reassessments at nominal time points of 6, 12, 52 and 86 weeks post randomisation. RESULTS: There were non-inferiority effects of CBT compared with STPP [treatment effect by final follow-up = -0.578, 95% confidence interval (CI) -2.948 to 4.104; p = 0.748]. There were no superiority effects for the two specialist treatments (CBT + STPP) compared with BPI (treatment effect by final follow-up = -1.898, 95% CI -4.922 to 1.126; p = 0.219). At final assessment there was no significant difference in the mean depressive symptom score between treatment groups. There was an average 49-52% reduction in depression symptoms by the end of the study. There were no differences in total costs or quality-of-life scores between treatment groups and prescribing a selective serotonin reuptake inhibitor (SSRI) during treatment or follow-up did not differ between the therapy arms and, therefore, did not mediate the outcome. CONCLUSIONS: The three psychological treatments differed markedly in theoretical and clinical approach and are associated with a similar degree of clinical improvement, cost-effectiveness and subsequent maintenance of lowered depressive symptoms. Both STPP and BPI offer an additional patient treatment choice, alongside CBT, for depressed adolescents attending specialist Child and Adolescent Mental Health Services. Further research should focus on psychological mechanisms that are associated with treatment response, the maintenance of positive effects, determinants of non-response and whether or not brief psychotherapies are of use in primary care and community settings. LIMITATIONS: Neither reason for SSRI prescribing or monitoring of medication compliance was controlled for over the course of the study, and the economic results were limited by missing data. TRIAL REGISTRATION: Current Controlled Trials ISRCTN83033550. FUNDING: This project was funded by the National Institute for Heath Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 12. See the National Institute for Heath Research Journals Library website for further project information. Funding was also provided by the Department of Health. The funders had no role in the study design, patient recruitment, data collection, analysis or writing of the study, any aspect pertinent to the study or the decision to submit to The Lancet.

Reduction in adolescent depression after contact with mental health services: a longitudinal cohort study in the UK.

BACKGROUND: Evidence regarding the association between service contact and subsequent mental health in adolescents is scarce, and previous findings are mixed. We aimed to longitudinally assess the extent to which depressive symptoms in adolescents change after contact with mental health services. METHODS: As part of a longitudinal cohort study, between April 28, 2005, and March 17, 2010, we recruited 1238 14-year-old adolescents and their primary caregivers from 18 secondary schools in Cambridgeshire, UK. Participants underwent follow-up assessment at months 18 and 36. Trained researchers assessed the adolescents for current mental disorder using the Schedule for Affective Disorders and Schizophrenia for School-Age Children Present and Lifetime version (K-SADS-PL). Caregivers and adolescents reported contact with mental health services in the year before baseline. Adolescents self-reported depressive symptoms (Mood and Feelings Questionnaire [MFQ]) at each timepoint. We assessed change in MFQ sum scores from baseline contact with mental health services using multilevel mixed-effects regression adjusted for sociodemographic, environmental, individual, and mental health confounders, with multiple imputation of missing data. We used propensity score weighting to balance confounders between treatment (users of mental health services) and control (non-users of mental health services) groups. We implemented an MFQ clinical cutoff following the results of receiver operating characteristic analysis. FINDINGS: 14-year-old adolescents who had contact with mental health services in the past year had a greater decrease in depressive symptoms than those without contact (adjusted coefficient -1·68, 95% CI -3·22 to -0·14; p=0·033). By age 17 years, the odds of reporting clinical depression were more than seven times higher in individuals without contact than in service users who had been similarly depressed at baseline (adjusted odds ratio 7·38, 1·73-31·50; p=0·0069). INTERPRETATION: Our findings show that contact with mental health services at age 14 years by adolescents with a mental disorder reduced the likelihood of depression by age 17 years. This finding supports the improvement of access to adolescent mental health services. FUNDING: Wellcome Trust, National Institute for Health Research.

Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial.

BACKGROUND: Psychological treatments for adolescents with unipolar major depressive disorder are associated with diagnostic remission within 28 weeks in 65-70% of patients. We aimed to assess the medium-term effects and costs of psychological therapies on maintenance of reduced depression symptoms 12 months after treatment. METHODS: We did this multicentre, pragmatic, observer-blind, randomised controlled superiority trial (IMPACT) at 15 National Health Service child and adolescent mental health service (CAMHS) clinics in three regions in England. Adolescent patients (aged 11-17 years) with a diagnosis of DSM IV major depressive disorder were randomly assigned (1:1:1), via a web-based randomisation service, to receive cognitive behavioural therapy (CBT) or short-term psychoanalytical therapy versus a reference brief psychological intervention. Randomisation was stochastically minimised by age, sex, self-reported depression sum score, and region. Patients and clinicians were aware of group allocation, but allocation was concealed from outcome assessors. Patients were followed up and reassessed at weeks 6, 12, 36, 52, and 86 post-randomisation. The primary outcome was self-reported depression symptoms at weeks 36, 52, and 86, as measured with the self-reported Mood and Feelings Questionnaire (MFQ). Because our aim was to compare the two psychological therapies with the brief psychosocial intervention, we first established whether CBT was inferior to short-term psychoanalytical psychotherapy for the same outcome. Primary analysis was by intention to treat. This trial is registered with Current Controlled Trials, number ISRCTN83033550. FINDINGS: Between June 29, 2010, and Jan 17, 2013, we randomly assigned 470 patients to receive the brief psychosocial intervention (n=158), CBT (n=155), or short-term psychoanalytical therapy (n=157); 465 patients comprised the intention-to-treat population. 392 (84%) patients had available data for primary analysis by the end of follow-up. Treatment fidelity and differentiation were established between the three interventions. The median number of treatment sessions differed significantly between patients in the brief psychosocial intervention group (n=6 [IQR 4-11]), CBT group (n=9 [5-14]), and short-term psychoanalytical therapy group (n=11 [5-23]; p<0·0001), but there was no difference between groups in the average duration of treatment (27·5 [SD 21·5], 24·9 [17·7], 27·9 [16·8] weeks, respectively; Kruskal-Wallis p=0·238). Self-reported depression symptoms did not differ significantly between patients given CBT and those given short-term psychoanalytical therapy at weeks 36 (treatment effect 0·179, 95% CI -3·731 to 4·088; p=0·929), 52 (0·307, -3·161 to 3·774; p=0·862), or 86 (0·578, -2·948 to 4·104; p=0·748). These two psychological treatments had no superiority effect compared with brief psychosocial intervention at weeks 36 (treatment effect -3·234, 95% CI -6·611 to 0·143; p=0·061), 52 (-2·806, -5·790 to 0·177; p=0·065), or 86 (-1·898, -4·922 to 1·126; p=0·219). Physical adverse events (self-reported breathing problems, sleep disturbances, drowsiness or tiredness, nausea, sweating, and being restless or overactive) did not differ between the groups. Total costs of the trial interventions did not differ significantly between treatment groups. INTERPRETATION: We found no evidence for the superiority of CBT or short-term psychoanalytical therapy compared with a brief psychosocial intervention in maintenance of reduced depression symptoms 12 months after treatment. Short-term psychoanalytical therapy was as effective as CBT and, together with brief psychosocial intervention, offers additional patient choice for psychological therapy, alongside CBT, for adolescents with moderate to severe depression who are attending routine specialist CAMHS clinics. FUNDING: National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme, and the Department of Health.

Clinical characteristics associated with the prescribing of SSRI medication in adolescents with major unipolar depression.

Unipolar major depressions (MD) emerge markedly during adolescence. National Institute for Health and Care Excellence (NICE) UK recommends psychological therapies, with accompanying selective serotonin reuptake inhibitors (SSRIs) prescribed in severe cases only. Here, we seek to determine the extent and rationale of SSRI prescribing in adolescent MD before entering a randomised clinical trial. SSRI prescribing, together with their clinical characteristics was determined in 465 adolescent patients with MD prior to receiving a standardised psychological therapy as part of the Improving mood with psychoanalytic and cognitive therapies (IMPACT) clinical trial. Overall, 88 (19 %) had been prescribed antidepressants prior to psychological treatment. The clinical correlates varied by gender: respectively, depression severity in boys and self-harming behaviours in girls. Prescribing also differed between clinical research centres. Medical practitioners consider severity of depression in boys as an indicator for antidepressant prescribing. Self-injury in girls appears to be utilised as a prescribing aid which is inconsistent with past and current revised UK NICE guidelines.

Perceived family functioning and friendship quality: cross-sectional associations with physical activity and sedentary behaviours.

BACKGROUND: This study examined the association of adolescent-reported family functioning and friendship quality with objectively-measured moderate to vigorous physical activity (MVPA), sedentary time, and self-reported sedentary behaviours. METHODS: Data are from the ROOTS study. MVPA and sedentary time were assessed using combined movement and heart rate sensing. Time spent TV viewing, using the internet, playing video games, doing homework and reading for pleasure was self-reported. Data on objectively-measured and self-reported outcomes for weekdays was available for 738 (age 14.5y, 55.7% female) and 800 (56.3% female) participants, respectively. Adolescents perceived family functioning and friendship quality (Two subscales: 'Good friendship qualities', 'Friendship difficulties') was assessed by questionnaire. Analyses were conducted using multi-level linear or logistic regression. RESULTS: Adolescents reporting better family functioning accumulated more MVPA on weekdays (beta; 95% confidence interval: 0.57; 0.17,0.98). Higher scores on the good friendship qualities subscale was associated with greater MVPA throughout the week (weekdays: 1.13; 0.62,1.65, weekend: 0.56; 0.09,1.02) and lower sedentary time on weekdays (-10.34; -17.03,-3.66). Boys from better functioning families were less likely to report playing video games at the weekend (OR; 95% confidence interval: 0.73; 0.57,0.93) or reading for pleasure (weekday: 0.73; 0.56,0.96 weekend: 0.75; 0.58,0.96). Boys who attained higher scores on the good friendship qualities scale were less likely to play video games at the weekend (0.61; 0.44,0.86) or report high homework on weekdays (0.54; 0.31,0.94). A higher score for good friendship qualities was associated with lower odds of girls playing video games during the week (0.76; 0.58,1.00) or reading for pleasure at the weekend (0.61; 0.42,0.88). Girls that reported fewer friendship difficulties had lower odds of high TV viewing (0.76; 0.62,0.93) or playing video games (0.71; 0.52,0.97) at the weekend, and lower odds of reading for pleasure (0.63; 0.49,0.81) or reporting high homework on weekdays (0.70; 0.52,0.95). DISCUSSION: Family functioning and friendship quality exhibit a complex pattern of association with physical activity and sedentary behaviour that varies by sex and day of the week. Findings highlight the potential value of targeting interpersonal aspects of the family and friendships as an adjunct to behaviour change interventions.

Precursors to aggression are evident by 6 months of age.

We tested the hypothesis that developmental precursors to aggression are apparent in infancy. Up to three informants rated 301 firstborn infants for early signs of anger, hitting and biting; 279 (93%) were assessed again as toddlers. Informants' ratings were validated by direct observation at both ages. The precursor behaviours were significantly associated with known risk factors for high levels of aggressiveness. Individual differences were stable from early infancy to the third year and predicted broader conduct problems. These findings suggest that some individuals set forth on the trajectory to high levels of aggression by 6 months of age. The findings have implications for developmental studies of aggression, clinical prevention and intervention strategies, and theoretical considerations regarding the detection of precursors in different domains of development.

Breakfast consumption and physical activity in adolescents: daily associations and hourly patterns.

BACKGROUND: The association between breakfast consumption and physical activity (PA) is inconclusive. OBJECTIVE: We aimed to investigate daily associations and hourly patterns of PA and breakfast consumption in British adolescents. DESIGN: Daily PA [accelerometry-derived moderate and vigorous physical activity (MVPA)] and breakfast consumption (diet diary) were measured simultaneously over 4 d in 860 adolescents (boys: 43.4%; mean ± SD age: 14.5 ± 0.5 y). Associations between MVPA and breakfast consumption were assessed by using a multilevel mixed-effects logistic regression separately by sex and for weekends and weekdays. Hourly patterns of MVPA by breakfast consumption status were displayed graphically, and differences were tested by using ANOVA. Multilevel linear regression was used to investigate differences in log MVPA on days when 570 inconsistent breakfast consumers ate or skipped breakfast. RESULTS: On weekends, boys and girls with higher MVPA were more likely to eat breakfast [OR (95% CI): boys, 1.78 (1.30, 2.45) (P < 0.001); girls, 2.30 (1.66, 3.08) (P < 0.001)] when adjusted for socioeconomic status, percentage of body fat, and total energy intake. Peak hourly MVPA differed for breakfast consumers compared with nonconsumers on weekends (P < 0.001). Inconsistent breakfast consumers did more MVPA on days when they ate breakfast [exponentiated ß coefficients (95% CIs): 1.2 (1.0, 1.5) on weekdays and 1.4 (1.1, 1.8) on weekends for boys and 1.6 (1.3, 2.1) on weekends for girls; all P < 0.03]. CONCLUSIONS: Eating breakfast was associated with higher MVPA on weekends. The time of peak MVPA differed between breakfast consumers and nonconsumers on weekends. Breakfast consumption at weekends is worth additional investigation to potentially inform PA promotion in adolescents.

Is wearing a pedometer associated with higher physical activity among adolescents?

OBJECTIVE: To examine whether wearing a pedometer was associated with higher objectively-measured physical activity (PA) among adolescents independent of other behavior change strategies, and whether this association differed by sex or day of wear. METHOD: In a parallel-group population-based cohort study, 892 adolescents (43.4% male, mean±SD age, 14.5±0.5years) from Eastern England were recruited. PA was measured (in 2005-2006) by accelerometry over four days; a sub-group (n=345) wore a pedometer coterminously with the accelerometer. Three-level (individual, day of wear and school level) multiple linear regression was used to examine the association between accelerometry (counts/min, cpm) and pedometer wear, stratified by sex and adjusted for weekday/weekend. RESULTS: For the entire cohort, there was a significant decline in cpm over four days (p<0.01). Girls wearing pedometers had higher mean cpm than those not wearing a pedometer, independent of BMI z-score, socio-economic status, weekday/weekend, and school clustering (ß=5.1; 95% CI: 0.8 to 9.5, p=0.02). This association was not seen in boys. CONCLUSION: Pedometer wear was associated with higher PA among adolescent girls, but not boys. Findings may support sex-specific intervention strategies. In addition to pedometer monitoring, additional strategies may be required to promote PA levels, especially among boys.

Known risk factors for violence predict 12-month-old infants' aggressiveness with peers.

This study tested the hypothesis that 12-month-old infants' use of force against peers is associated with known risk factors for violence. We conducted a prospective longitudinal study, which included laboratory observations of firstborn British infants (N = 271) during simulated birthday parties. No gender differences in aggressiveness were observed. The infants' observed aggressiveness was significantly correlated with mothers' mood disorder during pregnancy and with mothers' history of conduct problems. Infants' observed aggressiveness was correlated with parents' ratings of infants' anger and aggression, which were also predicted by mothers' mood disorder and history of conduct problems. Our findings indicate that infants at risk for serious aggression can already be identified when the motor ability to use physical force first enters the human repertoire.

Improving mood with psychoanalytic and cognitive therapies (IMPACT): a pragmatic effectiveness superiority trial to investigate whether specialised psychological treatment reduces the risk for relapse in adolescents with moderate to severe unipolar depression: study protocol for a randomised controlled trial.

BACKGROUND: Up to 70% of adolescents with moderate to severe unipolar major depression respond to psychological treatment plus Fluoxetine (20-50 mg) with symptom reduction and improved social function reported by 24 weeks after beginning treatment. Around 20% of non responders appear treatment resistant and 30% of responders relapse within 2 years. The specific efficacy of different psychological therapies and the moderators and mediators that influence risk for relapse are unclear. The cost-effectiveness and safety of psychological treatments remain poorly evaluated. METHODS/DESIGN: Improving Mood with Psychoanalytic and Cognitive Therapies, the IMPACT Study, will determine whether Cognitive Behavioural Therapy or Short Term Psychoanalytic Therapy is superior in reducing relapse compared with Specialist Clinical Care. The study is a multicentre pragmatic effectiveness superiority randomised clinical trial: Cognitive Behavioural Therapy consists of 20 sessions over 30 weeks, Short Term Psychoanalytic Psychotherapy 30 sessions over 30 weeks and Specialist Clinical Care 12 sessions over 20 weeks. We will recruit 540 patients with 180 randomised to each arm. Patients will be reassessed at 6, 12, 36, 52 and 86 weeks. Methodological aspects of the study are systematic recruitment, explicit inclusion criteria, reliability checks of assessments with control for rater shift, research assessors independent of treatment team and blind to randomization, analysis by intention to treat, data management using remote data entry, measures of quality assurance, advanced statistical analysis, manualised treatment protocols, checks of adherence and competence of therapists and assessment of cost-effectiveness. We will also determine whether time to recovery and/or relapse are moderated by variations in brain structure and function and selected genetic and hormone biomarkers taken at entry. DISCUSSION: The objective of this clinical trial is to determine whether there are specific effects of specialist psychotherapy that reduce relapse in unipolar major depression in adolescents and thereby costs of treatment to society. We also anticipate being able to utilise psychotherapy experience, neuroimaging, genetic and hormone measures to reveal what techniques and their protocols may work best for which patients. TRIAL REGISTRATION: Current Controlled Trials ISRCTN83033550.

Identifying early signs of aggression: psychometric properties of the Cardiff infant contentiousness scale.

Our aim was to develop an age-appropriate measure of early manifestations of aggression. We constructed a questionnaire about normative developmental milestones into which a set of items measuring infants' use of physical force against people and expressed anger were included. These items comprise the Cardiff Infant Contentiousness Scale (CICS). Evidence for the reliability and validity of the CICS is provided from analyses of a sample of N=310 British infants, assessed at a mean age of 6 months as part of a larger longitudinal study of the development of aggression. The informants' CICS ratings demonstrated reasonable levels of internal consistency and interrater agreement. Informants' ratings were validated by observations of infants' distress in response to restraint in a car seat. Longitudinal analyses revealed that contentiousness was stable over time and that contentiousness at 6 months predicted infants' later use of force with peers. When used in the company of other methods, the simple four-item CICS scale could serve as a useful screen for early manifestations of aggressiveness in human infants.

Socioemotional development in adolescents at risk for depression: the role of maternal depression and attachment style.

We examined the impact on adolescent socioemotional functioning of maternal postnatal depression (PND) and attachment style. We also investigated the role of earlier aspects of the child's development-attachment in infancy, and 5-year representations of family relationships. Ninety-one mother-child pairs, recruited in the postnatal period, were followed up at 13 years. Adolescents were interviewed about their friendships, and their level of emotional sensitivity and maturity were rated. Emotional sensitivity was heightened in girls whose mothers experienced PND; notably, its occurrence was also linked to insecure attachment in infancy and raised awareness of emotional components of family relationships at 5 years. High emotional sensitivity was also associated with adolescent depressed mood. Raised social maturity was predicted by a secure maternal attachment style and, for girls, by exposure to maternal PND. Precursors of adolescent social maturity were evident in the narrative coherence of 5-year family representations. Higher social maturity in the friendship interview was also associated with overall good adjustment.