Development and dissemination of collaborative family-oriented services: the case of community/day residential care in Israel.

The initiation, development, and dissemination of family-oriented programs are a unifying thread that highlights family therapy's contribution to the fields of mental/physical health and social services. These demanding tasks require an ecosystemic vision, a supportive larger context, and a range of skills. This article delineates the evolution of community and day residential care in Israel by examining processes at different ecological levels: the formulation and implementation of national social policy, the follow-up of two family-oriented facilities, one of which thrived while the other eventually closed, and the residential care provided to 1 family with 3 children. The analysis of this multilevel data highlights 4 facilitating/obstructing factors that have had major impact on family-oriented programs: support by both national and local sociopolitical-professional administration, program's management autonomy, staff training, support and development, and effective facility leadership that establishes and nurtures family-oriented organizational structure and culture.

Psychosocial predictors of weight loss and psychological adjustment following bariatric surgery and a weight-loss program: the mediating role of emotional eating.

OBJECTIVE: To examine a structural equation model of the effects of personal and interpersonal factors on treatment outcome of bariatric surgery and weight-loss program. METHOD: Forty-four participants of the surgery group and 47 participants of the diet group completed questionnaires before treatment and 1 year afterward. Predictor measures are as follows: social support, motivation for control, sense of control, self-esteem, neuroticism, fear of intimacy, and emotional eating (EE). OUTCOME MEASURES: Weight loss, quality of life, and mental health. RESULTS: Neurotic predisposition (NP), a latent variable indicated by neuroticism, low self-esteem, and fear of intimacy, had an effect on weight loss that was fully mediated by EE. NP also had an effect on quality of life improvement that was fully mediated by EE and weight loss in both treatment groups. DISCUSSION: Both NP and EE predict outcome of obesity treatments, but EE is the more proximal variable that mediates the effect of NP.

Adherence to honor code mediates the prediction of adolescent boys' conduct problems by callousness and socioeconomic status.

Although there is considerable evidence that culture-related factors are associated with aggressive behavior, their effect on the development of conduct problems (CP) has been insufficiently studied. This study focused on adherence to honor code (AHC), defined by the endorsement of honor culture attitudes at the identity narrative level of personality assessment, as a mediator in the prediction of CP by callousness, insecure attachment, and socioeconomic status. Our sample of 136 adolescent boys (M age = 15.02, SD = 1.48) oversampled high- and low-level Israeli schools, both academically and behaviorally. Structural equation modeling supported the theoretical model: AHC was a significant predictor of CP and partially mediated the prediction of CP by callousness and socioeconomic status. Insecure attachment predicted AHC but was not an independent predictor of CP.

Callous-Unemotional Traits and Effortful Control Mediate the Effect of Parenting Intervention on Preschool Conduct Problems.

Parenting intervention (PI) is an effective treatment for children's conduct problems (CP) that has been shown to be mediated by improved parenting practices and parenting self-efficacy. Recently, Hitkashrut's randomized controlled trial demonstrated that ineffective parenting (IP) mediated effects on callous-unemotional (CU) traits and effortful control (EC), while controlling for more general treatment effects on CP. These temperament and personality-based features predict the formation of early-onset antisocial trajectories with poor long-term prognosis. The objective of this study was to use Hitkashrut's 3-wave dataset to test posttreatment EC and CU mediation of treatment effect on 1-year follow-up CP, and to determine whether mediation by each child-level potential mediator remains significant when tested concurrently with the parenting mediator. Parents of 209 3-5 year-old preschoolers (163 boys; 46 girls), with subclinical-clinical range CP were assigned to 14-session co-parent training groups (n = 140 couples), or to minimal intervention control groups (n = 69 couples). Assessments were based on both parents' questionnaires. An intent-to-treat analysis showed that EC and CU traits simultaneously mediated treatment effects on CP in one EC/CU mediational model. The concurrent testing of child- and parent-level mediators showed mediation by IP and CU traits in the CU/IP model, and IP mediation in the EC/IP model. Similar results were obtained in mediational analyses that controlled for the shared variance between the mediators and CP at T2. Overall, the findings support an intervention model of coaching parents of high-CP children to promote moral self-regulatory competencies while concurrently applying behavioral methods that directly target CP.

Effects of Parent Training on Callous-Unemotional Traits, Effortful Control, and Conduct Problems: Mediation by Parenting.

Callous-unemotional (CU) traits and effortful control (EC) are personality and temperament traits implicated in early-onset antisocial trajectories. This secondary analysis of Hitkashrut's randomized controlled trial first tested parent training's effects on EC and CU traits while controlling for more general treatment effects on conduct problems (CP), and subsequently tested mediation by parenting. Prekindergarten teachers in three Israeli cities identified 209 3-5 year-old (163 boys; 46 girls) preschoolers with subclinical-clinical range conduct problems. All participants were Jewish ranging from ultra-orthodox to secular. They were assigned to 14-session co-parent training groups (n = 140 couples), or to minimal intervention control groups with referral to local services as necessary (n = 69 couples). We employed averaged indices of pre- and post-intervention questionnaires completed by both parents. The testing of all hypothesized models controlled for treatment effects on CP in order to strengthen the robustness of the analyses. We found significant concurrent treatment effects on CP and on either CU traits or EC. All effects were mediated by ineffective parenting (IP): a latent variable that was indicated by negative/inconsistent practices and perceived parenting inefficacy. This is the first demonstration of parenting mediated treatment effects on both EC and CU traits in a randomized controlled study conducted in everyday practice contexts. This finding supports a disruption model of change: the reduction of IP facilitates a caregiving environment that affects children's behavior and developing personality. The changing of personality and temperament characteristics implicated in early-onset pathways suggests an innovative prevention strategy for disruptive behavior disorders.

How anorexic-like are the symptom and personality profiles of aesthetic athletes?

PURPOSE: We tested the hypothesis that aesthetic athletes (AA) have anorexic-like eating attitudes and behaviors, share personality characteristics such as perfectionism and obsessiveness, and are at high risk of eating disorders. METHODS: We compared symptomatology, personality variables typical of anorexia nervosa, and lifetime eating disorder prevalence across four groups of Israeli women: 31 anorexics, 111 AA (mostly dancers), 68 nonaesthetic athletes (NAA), and 248 controls. All participants completed self-report measures of symptomatology, harm avoidance, perfectionism, obsessiveness, self-esteem, and self-rated facial attractiveness and were screened for eating disorders. Those screening positively were interviewed and diagnosed using the structured clinical interview for DSM-IV. RESULTS: Scores of the anorexic women differed from those of the three other groups in the expected direction on all variables. NAA scored similarly to controls, but had greater body satisfaction and less drive for thinness. Surprisingly, the AA did not differ from control women on any self-report measure. However, significantly more AA (11.7%) than NAA (5.8%) and controls (4.4%) had a lifetime diagnosis of eating disorder not otherwise specified (EDNOS). The eating attitudes and behavior of the 13 AA with a lifetime history of EDNOS fell intermediately between the anorexic women and the controls, whereas their personality profile resembled that of controls. CONCLUSIONS: Being a nonaesthetic female athlete in Israel appears to promote body esteem and offer some protection from a preoccupation with dieting. AA also appear to enjoy excellent psychological health; however, a subgroup has EDNOS and appears not to receive appropriate treatment for it. These results lend credibility to the existence of the diagnostic entity of anorexia athletica, proposed to be a subclinical, environmentally influenced eating disorder with a favorable prognosis.

Association of the serotonin transporter gene with smoking behavior.

OBJECTIVE: In an ongoing molecular genetic study of temperament, participants were genotyped to examine the association of smoking with two polymorphisms of the serotonin transporter gene (SERT): the promoter region, 5-HTTLPR, and an intronic variable-number-of-tandem-repeats region (VNTR). METHOD: Full information was available for 330 families, and 244 "ever smokers" were identified (54 past smokers, 190 current smokers). The average number of cigarettes smoked per day was 13.12, and the mean Fagerstrom Tolerance Questionnaire score was 4.79. Associations of genotype, Tridimensional Personality Questionnaire scores, and smoking phenotype were tested by using a robust family design with a variance-components framework and by case-control analysis. RESULTS: There was a significant excess of the 5-HTTLPR long allele with the 12-repeat VNTR in current smokers, past smokers, and ever smokers, compared to participants who had never smoked. The results from the population design were confirmed in the family-based analysis. No association was observed between two quantitative measures of smoking and the polymorphisms. A weak association was observed between novelty seeking and the VNTR polymorphism and between reward and 5-HTTLPR. Smokers, regardless of gender, scored significantly higher on novelty seeking and did not differ on harm avoidance or reward. CONCLUSIONS: There was a highly significant association between SERT and the categorical definition of smoking, irrespective of dependence level, suggesting that this gene influences the initiation of smoking. Mediation analysis failed to substantiate the hypothesis that novelty seeking partially mediates the effect of SERT on smoking. SERT appears to independently contribute to novelty seeking and smoking.

Prevalence and description of selective mutism in immigrant and native families: a controlled study.

OBJECTIVE: To assess the incidence of selective mutism (SM) in West Jerusalem's state preschools and evaluate social anxiety/phobia disposition (SAP), social competence (SC), markers of neurodevelopmental delay/disorder (NDD), mothers' psychological adjustment, and marital conflict in immigrant and native children with SM and their matched controls. METHOD: Mothers of 9 immigrant and 10 native children with SM and their matched controls completed questionnaires evaluating themselves, their marriages, and their children. RESULTS: A response rate of 30% (19/64) was obtained. The general prevalence of SM was 0.76%, while the rate among immigrants was 2.2%. Except for mothers' adjustment, all immigrant/native group effects were significant. There were significant interactions between the SM/control and immigrant/native groups for SAP, NDD, and SC. Immigrant children with SM had higher SAP and SC scores and lower NDD scores than native children with SM. CONCLUSIONS: This study distinguished between homogenous (socially anxious) and comorbid children with SM. In this sample, the disorder appeared to be associated with a combination of a specific diathesis (SAP) with intrinsic (NDD) and/or environmental (family immigration) vulnerabilities. Marital discord appeared to be a general risk factor for SM.

Health-related quality of life changes and weight reduction after bariatric surgery vs. a weight-loss program.

BACKGROUND: The present study compared the outcome of bariatric surgery against a uniform high-level weightloss program which included vigorous physical exercises, behavior modification and nutritional advice. METHOD: 44 subjects who underwent bariatric surgery and 47 subjects participating in a weight-loss program completed the Medical Outcomes Study Short Form- 36 (SF-36), the Mental Health Inventory (MHI) and the Rosenberg Self-Esteem scale, prior to surgery/diet and one year afterwards. RESULTS: Post-surgery subjects had a greater mean weight loss (34.70% ± 11.94) than subjects in the weight-loss program, even though their weight reduction was also clinically significant (9.23% ± 8.31). Post-surgery subjects showed significant improvements in SF-36, MHI, and selfesteem. The diet group improved in SF-36 total score, physical functioning, health perceptions, and vitality scales. LIMITATIONS: Differences in background variables and short follow-up. CONCLUSIONS: Surgery outcomes were significantly better in terms of both weight reduction and psychological adjustment compared to highly motivated participants in a prestigious, cutting edge weight-loss program.

Promoting self-regulation and cooperation in pre-kindergarten children with conduct problems: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness and mechanisms of Hitkashrut, a "common elements" co-parent training (PT) program for early intervention with preschoolers (3-5 years of age) at risk for conduct problems (CP). METHOD: A randomized controlled trial with 140 participants in PT and 69 in a minimal intervention control group. The primary outcome (presence of CP) was assessed at pre-intervention, post-intervention, and 1-year follow-up. Callous-unemotional traits, effortful control, parental distress, negative/inconsistent parenting, and couple relationship quality were assessed at pre- and post-intervention, whereas callous-unemotional traits and effortful control were also assessed in the PT group at follow-up. Retention was 87.1% at post-intervention and 60% at follow-up. Hitkashrut incorporated evidence-based components of established PT programs into a culturally adapted protocol. The facilitators were trained and supervised psychologists working in Israel's Educational Psychology Services. RESULTS: Intervention effect (Cohen's d) was large at post-intervention (ES = .76, p < .001), and an additional medium effect was found at follow-up (ES = 0.63, p < .001). Parallel post-intervention and follow-up intervention effects were also found in the degree of clinically significant improvements. Effects of the intervention on callous-unemotional traits (ES = 0.85, p < .001) and effortful control (ES = 0.47, p < .001) were maintained at follow-up. Follow-up improvement in CP was mediated by improvements in parental practices and distress. CONCLUSIONS: Hitkashrut's implementation and subsequent dissemination in real-world settings demonstrates the potential effectiveness of common elements programs to promote innovations within service-delivery systems. Improvements in dispositional variables and the mediated follow-up effect support theoretical cascade models that emphasize early developmental malleability and the growing preventive effects of PT's facilitated parental changes on disruptive developmental trajectories. Clinical trial registration information - The effect of a "common elements" co-parent training program (called 'Hitkashrut') on conduct in preschoolers at risk for conduct problems; http://www.anzctr.org.au; ACTRN12612000148875.

Sex differences in parental reaction to pediatric illness.

The 'Tend-and Befriend' hypothesis claims that whereas the response of males to stress is Fight-or-Flight, females respond with Tend-and-Befriend. We tested this hypothesis with a sample of 110 couples whose children had undergone neurosurgery. Both mothers and fathers answered questionnaires measuring levels of tending, befriending, stress, anxiety, and depression. As hypothesized, mothers scored higher than fathers did on all measures. However, according to the Tend-and Befriend hypothesis, the sex difference in tending and befriending should be more pronounced in couples suffering from high-stress in comparison to couples suffering from low-stress. This hypothesis was not supported by the data. We suggest that the heightened tending and befriending of women is not a reaction to stress, instead it is a persistent maternal characteristic. Moreover, we suggest that maternal anxiety and depression result from a heightened maternal sensitivity, selected for caregiving. The study results imply that support interventions should be aimed mostly at mothers, since they experience more distress, in comparison to fathers.

Maternal adaptation to pediatric neurosurgical diagnosis: a growth curve analysis.

OBJECTIVE: To describe trajectories of change in maternal adaptation to chronic pediatric neurosurgical diagnosis and to identify variables predicting the level and rate of adaptation. METHODS: One hundred and thirty seven mothers of children diagnosed with neurosurgical illness participated. Mothers reported socio-demographic variables, neuroticism, optimism, spouse support, mental health, and personal growth. The coordinating nurse assessed illness variables. Data were collected from diagnosis to 32+months post-diagnosis. RESULTS: Results showed poor maternal mental health at diagnosis, followed by a gradual improvement over the next 18 months, and then a slight regression. Optimism, spouse support and religiosity were identified as resistance factors, while neuroticism, treatment needs, maternal age, and maternal education were identified as risk factors. The rate of change in mental health was moderated by neuroticism. CONCLUSIONS: Maternal adaptation to pediatric illness changes over time. The trajectories of adaptation vary in relation to personal, social and medical variables.

A gender-moderated model of family relationships and adolescent adjustment.

The objective of this study was to explain why adolescent girls with conduct problems (CP) are more at risk than boys to develop emotional distress (ED) in a sample composed of Israeli-born and immigrant youth from Ethiopia and the former Soviet Union (n = 305, ages 14-18). We tested a structural equation model and found a very good fit to the data for both immigrant and nonimmigrant groups. The hypothesized effects of gender, CP, and parent-child relationships on ED were significant, whereas the effect of family discord was mediated by parent-child relationships. Subsequently, we used multiple-group analyses to test the two interaction hypotheses. We found significantly higher associations between CP and family discord and between ED and negative parent-child relationships in girls compared to boys.

Anorexia nervosa, perfectionism, and dopamine D4 receptor (DRD4).

The dopamine D4 receptor (DRD4), a well-characterized, polymorphic gene, is an attractive candidate for contributing risk to disordered eating and anorexia nervosa (AN). We tested association using UNPHASED for 5 DRD4 polymorphic loci, 3 promoter region SNPs (C-521T, C-616G, A-809G), the 120 bp promoter region tandem duplication and the exon III repeat, in 202 AN trios and 418 control families. Since perfectionism characterizes AN, we tested these five loci for association with the Child and Adolescent Perfectionism Scale (CAPS) in the AN and control groups. Single locus analysis showed significant association between the 'C' C-521T allele and AN. Haplotype analysis also showed significant association, particularly a 4-locus haplotype (exon III&120 bp repeat&C-521T&A-809G). Association was also observed between DRD4 and CAPS scores both for AN and control subjects. The insulin-like growth factor 2 (IGF2) and the arginine vasopressin 1a receptor (AVPR1a), previously shown to be associated with disordered eating, were also associated with CAPS scores. Three genes associated with AN were also associated with perfectionism. Personality traits are potential endophenotypes for understanding the etiology of eating disorders and one of the several pathways to eating pathology may be mediated by the impact of DNA sequences on perfectionism.

Association between a vasopressin receptor AVPR1A promoter region microsatellite and eating behavior measured by a self-report questionnaire (Eating Attitudes Test) in a family-based study of a nonclinical population.

OBJECTIVES: Considerable evidence including twin and family studies suggests that biologic determinants interact with cultural cues in the etiology of anorexia and bulimia nervosa. A gene that makes "biologic sense" in contributing susceptibility to these disorders, and to our knowledge not previously investigated for this phenotype, is the vasopressin receptor (AVPR1A), which we have tested for association with eating pathology. METHODS: We genotyped 280 families with same-sex siblings for two microsatellites in the promoter region of the AVPR1A gene. Siblings completed the 26-item Eating Attitudes Test (EAT) and the Drive for Thinness (DT) and Body Dissatisfaction (BD) subscales of the Eating Disorders Inventory (EDI). The Quantitative Transmission Disequilibrium Test program (QTDT), which employs flexible and powerful variance-components procedures, was used to test for an association between EAT scores and the two AVPR1A promoter region microsatellites, RS1 and RS3. RESULTS: A significant association (p = .036) was detected between the RS3 microsatellite and EAT scores. The strongest association was between RS3 and the Dieting subscale of the EAT (p = .011). A significant association was also observed between the EDI-DT and the RS3 microsatellit (p = .0450). CONCLUSIONS: We demonstrate for the first time an association between a microsatellite polymorphism in the AVPR1A promoter region and scores on the EAT as well as with the EDI-DT. The strongest association was observed between the RS3 microsatellite and the Dieting subscale of the EAT. The relevant phenotype appears to tap severe dietary restriction for weight loss purposes.