Nurse-Moderated Internet-Based Support for New Mothers: Non-Inferiority, Randomized Controlled Trial.

BACKGROUND: Internet-based interventions moderated by community nurses have the potential to improve support offered to new mothers, many of whom now make extensive use of the Internet to obtain information about infant care. However, evidence from population-based randomized controlled trials is lacking. OBJECTIVE: The aim of this study was to test the non-inferiority of outcomes for mothers and infants who received a clinic-based postnatal health check plus nurse-moderated, Internet-based group support when infants were aged 1-7 months as compared with outcomes for those who received standard care consisting of postnatal home-based support provided by a community nurse. METHODS: The design of the study was a pragmatic, preference, non-inferiority randomized control trial. Participants were recruited from mothers contacted for their postnatal health check, which is offered to all mothers in South Australia. Mothers were assigned either (1) on the basis of their preference to clinic+Internet or home-based support groups (n=328), or (2) randomly assigned to clinic+Internet or home-based groups if they declared no strong preference (n=491). The overall response rate was 44.8% (819/1827). The primary outcome was parenting self-competence, as measured by the Parenting Stress Index (PSI) Competence subscale, and the Karitane Parenting Confidence Scale scores. Secondary outcome measures included PSI Isolation, Interpersonal Support Evaluation List-Short Form, Maternal Support Scale, Ages and Stages Questionnaire-Social-Emotional and MacArthur Communicative Development Inventory (MCDI) scores. Assessments were completed offline via self-assessment questionnaires at enrolment (mean child age=4.1 weeks, SD 1.3) and again when infants were aged 9, 15, and 21 months. RESULTS: Generalized estimating equations adjusting for post-randomization baseline imbalances showed that differences in outcomes between mothers in the clinic+Internet and home-based support groups did not exceed the pre-specified margin of inferiority (0.25 of a SD) on any outcome measure at any follow-up assessment, with the exception of MCDI scores assessing children's language development at 21 months for randomized mothers, and PSI Isolation scores at 9 months for preference mothers. CONCLUSION: Maternal and child outcomes from a clinic-based postnatal health check plus nurse-moderated Internet-based support were not inferior to those achieved by a universal home-based postnatal support program. Postnatal maternal and infant support using the Internet is a promising alternative to home-based universal support programs. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry Number (ANZCTR): ACTRN12613000204741; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363712&isReview=true (Archived by WebCite at http://www.webcitation.org/6rZeCJ3k1).

Quality of childcare influences children's attentiveness and emotional regulation at school entry.

OBJECTIVE: To examine the association between domain-specific qualities of formal childcare at age 2-3 years and children's task attentiveness and emotional regulation at age 4-5 and 6-7 years. STUDY DESIGN: We used data from the Longitudinal Study of Australian Children (n = 1038). Three domain-specific aspects of childcare quality were assessed: provider and program characteristics of care, activities in childcare, and carer-child relationship. Two self-regulatory abilities were considered: task attentiveness and emotional regulation. Associations between domain-specific qualities of childcare and self-regulation were investigated in linear regression analyses adjusted for confounding, with imputation for missing data. RESULTS: There was no association between any provider or program characteristics of care and children's task attentiveness and emotional regulation. The quality of activities in childcare were associated only with higher levels of emotional regulation at age 4-5 years (ß = 0.24; 95% CI, 0.03-0.44) and 6-7 years (ß = 0.26; 95% CI, 0.04-0.48). Higher-quality carer-child relationships were associated with higher levels of task attentiveness (ß = 0.20; 95% CI, 0.05-0.36) and emotional regulation at age 4-5 years (ß = 0.19; 95% CI, 0.04-0.34) that persisted to age 6-7 years (ß = 0.26; 95% CI, 0.10-0.42; ß = 0.31; 95% CI, 0.16-0.47). CONCLUSION: Among children using formal childcare, those who experienced higher-quality relationships were better able to regulate their attention and emotions as they started school. Higher emotional regulation was also observed for children engaged in more activities in childcare. Beneficial effects were stable over time.

Can screening 4-5 year olds accurately identify children who will have teacher-reported mental health problems when children are aged 6-7 years?

OBJECTIVE: To assess the screening accuracy of information obtained from parents of 4-5-year-old children for the purpose of identifying the children who have teacher-reported mental health problems when they are aged 6-7 years. METHOD: The study used data from the Longitudinal Study of Australian Children (LSAC) obtained when children were aged 4-5 years and 6-7 years. The level of children's mental health problems was assessed using the Strengths and Difficulties Questionnaire (SDQ) completed by parents when children were aged 4-5 years and by teachers when children were aged 6-7 years (n=2163). When children were aged 4-5 years, parenting skills were assessed using three questionnaires developed for the parent-completed LSAC questionnaire and maternal mental health was assessed using the Kessler Psychological Distress Scale (K6). RESULTS: When the level of parent-reported childhood mental health problems at 4-5 years old was used to identify children with teacher-reported mental health problems (i.e. a score in the "abnormal" range of the teacher-reported SDQ Total Difficulties Scale) when the children were aged 6-7 years, sensitivity was 26.8%, positive predictive value was 22.8%, and specificity was 92.9%. The addition of further information about the characteristics of children and their parents made only a small improvement to screening accuracy. CONCLUSIONS: Targeted interventions for preschool children may have the potential to play an important role in reducing the prevalence of mental health problems during the early school years. However, current capacity to accurately identify preschoolers who will experience teacher-reported mental health problems during the early school years is limited.

An equivalence evaluation of a nurse-moderated group-based internet support program for new mothers versus standard care: a pragmatic preference randomised controlled trial.

BACKGROUND: All mothers in South Australia are offered a clinic or home-visit by a Child and Family Health community nurse in the initial postnatal weeks. Subsequent support is available on request from staff in community clinics and from a telephone helpline. The aim of the present study is to compare equivalence of a single clinic-based appointment plus a nurse-moderated group-based internet intervention when infants were aged 0-6 months versus a single home-visit together with subsequent standard services (the latter support was available to mothers in both study groups). METHODS/DESIGN: The evaluation utilised a pragmatic preference randomised trial comparing the equivalence of outcomes for mothers and infants across the two study groups. Eligible mothers were those whose services were provided by nurses working in one of six community clinics in the metropolitan region of Adelaide. Mothers were excluded if they did not have internet access, required an interpreter, or their nurse clinician recommended that they not participate due to issues such as domestic violence or substance abuse. Randomisation was based on the service identification number sequentially assigned to infants when referred to the Child and Family Health Services from birthing units (this was done by administrative staff who had no involvement in recruiting mothers, delivering the intervention, or analyzing results for the study). Consistent with design and power calculations, 819 mothers were recruited to the trial. The primary outcomes for the trial are parents' sense of competence and self-efficacy measured using standard self-report questionnaires. Secondary outcomes include the quality of mother-infant relationships, maternal social support, role satisfaction and maternal mental health, infant social-emotional and language development, and patterns of service utilisation. Maternal and infant outcomes will be evaluated using age-appropriate questionnaires when infants are aged <2 months (pre-intervention), 9, 15, and 21 months. DISCUSSION: We know of no previous study that has evaluated an intervention that combines the capacity of nurse and internet-based services to improve outcomes for mothers and infants. The knowledge gained from this study will inform the design and conduct of community-based postnatal mother and child support programs. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12613000204741.

Experiences of Caregivers and At-Risk Children Enrolled in a Prospective Pregnancy-Birth Cohort Study into the Causes of Type 1 Diabetes: The ENDIA Study.

BACKGROUND: We sought research experiences of caregivers and their children were enrolled in the Environmental Determinants of Islet Autoimmunity (ENDIA) study. METHODS: ENDIA is a pregnancy-birth cohort investigating early-life causes of type 1 diabetes (T1D). Surveys were sent to 1090 families between June 2021 and March 2022 with a median participation of >5 years. Caregivers completed a 12-item survey. Children ≥ 3 years completed a four-item survey. RESULTS: The surveys were completed by 550/1090 families (50.5%) and 324/847 children (38.3%). The research experience was rated as either "excellent" or "good" by 95% of caregivers, and 81% of children were either "ok", "happy" or "very happy". The caregivers were motivated by contributing to research and monitoring their children for T1D. Relationships with the research staff influenced the experience. The children most liked virtual reality headsets, toys, and "helping". Blood tests were least liked by the children and were the foremost reason that 23.4% of the caregivers considered withdrawing. The children valued gifts more than their caregivers. Only 5.9% of responses indicated dissatisfaction with some aspects of the protocol. The self-collection of samples in regional areas, or during the COVID-19 pandemic restrictions, were accepted. CONCLUSIONS: This evaluation identified modifiable protocol elements and was conducted to further improve satisfaction. What was important to the children was distinct from their caregivers.

Cognitive and electroencephalographic disturbances in children with attention-deficit/hyperactivity disorder and sleep problems: new insights.

There is overlap between the behavioural symptoms and disturbances associated with Attention-Deficit/Hyperactivity Disorder (AD/HD) and sleep problems. The aim of this study was to examine the extent of overlap in cognitive and electrophysiological disturbances identified in children experiencing sleep problems and children with AD/HD or both. Four groups (aged 7-18) were compared: children with combined AD/HD and sleep problems (n=32), children with AD/HD (n=52) or sleep problems (n=36) only, and children with neither disorder (n=119). Electrophysiological and cognitive function measures included: absolute EEG power during eyes open and eyes closed, event-related potential (ERP) components indexing attention and working memory processes (P3), and a number of standard neuropsychological tests. Children with symptoms of both AD/HD and sleep problems had a different profile from those of children with either AD/HD or sleep problems only. These findings suggest it is unlikely that disturbances in brain and cognitive functioning associated with sleep problems also give rise to AD/HD symptomatology and consequent diagnosis. Furthermore, findings suggest that children with symptoms of both AD/HD and sleep problems may have a different underlying aetiology than children with AD/HD-only or sleep problems-only, perhaps requiring unique treatment interventions.

A systematic review and meta-analysis of effects of early life non-cognitive skills on academic, psychosocial, cognitive and health outcomes.

Success in school and the labour market relies on more than high intelligence. Associations between "non-cognitive" skills in childhood, such as attention, self-regulation, and perseverance, and later outcomes have been widely investigated. In a systematic review of this literature, we screened 9553 publications, reviewed 554 eligible publications, and interpreted results from 222 better quality publications. Better quality publications comprised randomised experimental and quasi-experimental studies (EQIs), and observational studies that made reasonable attempts to control confounding. For academic achievement outcomes there were 26 EQI publications but only 14 were available for meta-analysis with effects ranging from 0.16 to 0.37SD. However, within sub-domains effects were heterogeneous. The 95% prediction interval for literacy was consistent with negative, null and positive effects (-0.13 to 0.79). Similarly heterogeneous findings were observed for psychosocial, cognitive and language, and health outcomes. Funnel plots of EQIs and observational studies showed asymmetric distributions and potential for small study bias. There is some evidence that non-cognitive skills associate with improved outcomes. However, there is potential for small study and publication bias that may over-estimate true effects, and heterogeneity of effect estimates spanned negative, null and positive effects. The quality of evidence from EQIs under-pinning this field is lower than optimal and more than a third of observational studies made little or no attempt to control confounding. Interventions designed to develop children's non-cognitive skills could potentially improve outcomes. The inter-disciplinary researchers interested in these skills should take a more strategic and rigorous approach to determine which interventions are most effective.

Has the Prevalence of Child and Adolescent Mental Disorders in Australia Changed Between 1998 and 2013 to 2014?

OBJECTIVE: This study examined whether the 12-month prevalence of major depressive disorder (MDD), attention-deficit/hyperactivity disorder (ADHD), and conduct disorder (CD) among 6- to 17-year-olds in Australia changed between 1998 and 2013 to 2014. It also investigated whether changes in the prevalence of disorders over this time varied for children living in families containing 2 parents versus single parents, and families with high versus low income. METHOD: The study used data from national surveys conducted in Australia in 1998 (N = 3,597) and 2013 to 2014 (N = 5,359). In both surveys, the participating individuals were randomly selected from all 6- to 17-year-olds in Australia, and mental disorders were assessed using the Diagnostic Interview Schedule for Children Version IV (DISC-IV), completed by parents. RESULTS: There was little change in the overall prevalence of mental disorders between 1998 (12.5%, 95% CI = 11.4-13.7) and 2013 to 2014 (11.1%, 95% CI = 10.1-12.2). Although there were some differences in the changes for children with different disorders, most were small in magnitude. Specifically, MDD prevalence increased from 2.1% (95% CI = 1.7-2.7) to 3.2% (95% CI = 2.7-3.8), ADHD prevalence declined from 9.9% (95% CI = 8.9-10.9) to 7.8% (95% CI = 6.9-8.7), and CD prevalence declined from 2.7% (95% CI = 2.2-3.3) to 2.1% (95% CI = 1.7-2.7). There was a persisting pattern of higher prevalence among children living in single-parent and low-income households. CONCLUSION: Lack of change at a population level in the prevalence of child mental disorders suggests that new innovations in research, policy, and practice are needed to successfully address the major public health problem posed by child and adolescent mental disorders in the community.

The Prevalence of Stimulant and Antidepressant Use by Australian Children and Adolescents with Attention-Deficit/Hyperactivity Disorder and Major Depressive Disorder: A National Survey.

OBJECTIVES: To identify the prevalence of stimulant and antidepressant medication use by children and adolescents with symptoms meeting the criteria for attention-deficit/hyperactivity disorder (ADHD) and major depressive disorder (MDD) in Australia. To identify factors associated with stimulant and antidepressant use by children and adolescents in Australia. METHODS: Data are from a nationally representative sample of 4- to 17-year-olds (n = 6310). Parents completed the Diagnostic Interview Schedule for Children-Version IV (DISC-IV) and the Strengths and Difficulties Questionnaire. Eleven- to 17-year-olds completed a self-report version of the DISC-IV MDD module. Interviewers recorded prescribed medications used by participants in the previous 2 weeks. RESULTS: During a 2-week period, 1.3% of all 4- to 17-year-olds and 13.7% of those with symptoms meeting the criteria for ADHD had used stimulant medication, while 0.9% of all 4- to 17-year-olds and 13.4% with MDD had used antidepressants. In total, 22.6% of those using stimulant medications and 57.7% using antidepressant medications did not have symptoms meeting criteria for ADHD or MDD, respectively. Among 11- to 17-year-olds, 5.6% of those with adolescent-only-reported MDD, 10.9% of those with parent/carer-only-reported MDD, and 25.7% of those with MDD reported by both parents/carers and adolescents were using antidepressant medications. CONCLUSIONS: Only a minority of 4- to 17-year-olds with ADHD and MDD were being treated with stimulant or antidepressant medication. The percentage of adolescents with MDD using antidepressant medications varied depending on whether adolescents, parents/carers, or both identified the presence of MDD. This highlights the importance of using information from both these informants when assessing and treating adolescent depressive disorder.

Do early life cognitive ability and self-regulation skills explain socio-economic inequalities in academic achievement? An effect decomposition analysis in UK and Australian cohorts.

Socio-economic inequalities in academic achievement emerge early in life and are observed across the globe. Cognitive ability and "non-cognitive" attributes (such as self-regulation) are the focus of many early years' interventions. Despite this, little research has compared the contributions of early cognitive and self-regulation abilities as separate pathways to inequalities in academic achievement. We examined this in two nationally representative cohorts in the UK (Millennium Cohort Study, n = 11,168; 61% original cohort) and Australia (LSAC, n = 3028; 59% original cohort). An effect decomposition method was used to examine the pathways from socio-economic disadvantage (in infancy) to two academic outcomes: 'low' maths and literacy scores (based on bottom quintile) at age 7-9 years. Risk ratios (RRs, and bootstrap 95% confidence intervals) were estimated with binary regression for each pathway of interest: the 'direct effect' of socio-economic disadvantage on academic achievement (not acting through self-regulation and cognitive ability in early childhood), and the 'indirect effects' of socio-economic disadvantage acting via self-regulation and cognitive ability (separately). Analyses were adjusted for baseline and intermediate confounding. Children from less advantaged families were up to twice as likely to be in the lowest quintile of maths and literacy scores. Around two-thirds of this elevated risk was 'direct' and the majority of the remainder was mediated by early cognitive ability and not self-regulation. For example in LSAC: the RR for the direct pathway from socio-economic disadvantage to poor maths scores was 1.46 (95% CI: 1.17-1.79). The indirect effect of socio-economic disadvantage through cognitive ability (RR = 1.13 [1.06-1.22]) was larger than the indirect effect through self-regulation (1.05 [1.01-1.11]). Similar patterns were observed for both outcomes and in both cohorts. Policies to alleviate social inequality (e.g. child poverty reduction) remain important for closing the academic achievement gap. Early interventions to improve cognitive ability (rather than self-regulation) also hold potential for reducing inequalities in children's academic outcomes.

Usage, adherence and attrition: how new mothers engage with a nurse-moderated web-based intervention to support maternal and infant health. A 9-month observational study.

OBJECTIVES: To identify factors predicting use, adherence and attrition with a nurse-moderated web-based group intervention designed to support mothers of infants aged 0-6 months. DESIGN: 9-Month observational study. SETTING: Community maternal and child health service. PARTICIPANTS: 240 mothers attending initial postnatal health checks at community clinics who were randomly assigned to the intervention arm of a pragmatic preference randomised trial (total randomised controlled trial, n=819; response rate=45%). INTERVENTION: In the first week (phase I), mothers were assisted with their first website login by a research assistant. In weeks 2-7 (phase II), mothers participated in the web-based intervention with an expectation of weekly logins. The web-based intervention was comparable to traditional face-to-face new mothers' groups. During weeks 8-26 (phase III), mothers participated in an extended programme at a frequency of their choosing. PRIMARY OUTCOME MEASURES: Number of logins and posted messages. Standard self-report measures assessed maternal demographic and psychosocial characteristics. RESULTS: In phase II, the median number of logins was 9 logins (IQR=1-25), and in phase III, it was 10 logins (IQR=0-39). Incident risk ratios from multivariable analyses indicated that compared to mothers with the lowest third of logins in phase I, those with the highest third had 6.43 times as many logins in phase II and 7.14 times in phase III. Fifty per cent of mothers logged-in at least once every 30 days for 147 days after phase I and 44% logged-in at least once in the last 30 days of the intervention. Frequency of logins during phase I was a stronger predictor of mothers' level of engagement with the intervention than their demographic and psychosocial characteristics. CONCLUSIONS: Mothers' early use of web-based interventions could be employed to customise engagement protocols to the circumstances of individual mothers with the aim of improving adherence and reducing attrition with web-based interventions. TRIAL REGISTRATION NUMBER: ACTRN12613000204741; Results.

Is greater improvement in early self-regulation associated with fewer behavioral problems later in childhood?

The aim of this study was to determine whether the extent of improvement in self-regulation achieved between ages 4 and 6 years is associated with the level of behavioral problems later in childhood. Participants were 4-year-old children (n = 510) attending preschools in South Australia. Children's level of self-regulation was assessed using the parent-completed Devereux Early Childhood Assessment when children were aged 4, 5, and 6. Children's level of behavioral problems was assessed using total, internalizing, and externalizing scores on parent- and teacher-rated Strengths and Difficulties Questionnaires (SDQs) when children were 6 years old. Random effects regression was used to describe the changes to children's self-regulation between 4 and 6 years. Linear regression models were then used to determine the strength of the association between the extent of self-regulation improvement and level of behavioral problems. Greater improvement in self-regulation, adjusted for family characteristics and baseline self-regulation scores, was associated with lower levels of parent- (B = -3.57, 95% confidence interval [CI] [-4.49, -2.65]) and teacher-rated SDQ total difficulties scores at 6 years (B = -2.42, 95% CI [-3.50, -1.34]). These effects remained after adjustment for level of parent-rated behavioral problems at 4 years. Similar effects were found for internalizing and externalizing scores at age 6 years. The results highlight the importance of improvements in self-regulation from 4-6 years for childhood behavioral problems during the early school years. Children with lower levels of improvement in self-regulation early in life are at risk for higher levels of behavioral problems both at home and at school.

Metacognitive processes in emotion recognition: are they different in adults with Asperger's disorder?

Deficits in emotion recognition and social interaction characterize individuals with Asperger's Disorder (AS). Moreover they also appear to be less able to accurately use confidence to gauge their emotion recognition accuracy (i.e., metacognitive monitoring). The aim of this study was to extend this finding by considering both monitoring and control processes in emotion recognition among adults with AS. Those with AS were found to have difficulties acting on the basis of their metacognitive monitoring despite showing no deficits in their ability to discriminate accurate from inaccurate decisions. It is suggested that adults with AS have difficulties interacting socially because they are less able to assess when they are making accurate emotion recognition decisions despite having the capability to do so.

Can gaze avoidance explain why individuals with Asperger's syndrome can't recognise emotions from facial expressions?

Research has shown that individuals with Autism Spectrum Disorders (ASD) have difficulties recognising emotions from facial expressions. Since eye contact is important for accurate emotion recognition, and individuals with ASD tend to avoid eye contact, this tendency for gaze aversion has been proposed as an explanation for the emotion recognition deficit. This explanation was investigated using a newly developed emotion and mental state recognition task. Individuals with Asperger's Syndrome were less accurate at recognising emotions and mental states, but did not show evidence of gaze avoidance compared to individuals without Asperger's Syndrome. This suggests that the way individuals with Asperger's Syndrome look at faces cannot account for the difficulty they have recognising expressions.