Online therapy with families - what can families tell us about how to do this well? A qualitative study assessing families' experience of remote Dyadic Developmental Psychotherapy compared to face-to-face therapy.

Dyadic Developmental Psychotherapy (DDP) is a family-based therapy for adopted children aiming to achieve secure attachment between the child and parent. Due to restrictions under the COVID-19 pandemic, delivery of DDP transitioned from face-to-face to online methods. This study aimed to explore families experience of online DDP compared to face-to-face DDP, looking at the advantages and disadvantages of remote delivery methods and the implications this has on future service delivery for clinicians. Semi-structured interviews with 6 families were conducted online. Analysis of transcripts using Interpretative Phenomenological Analysis (IPA) revealed four superordinate themes: environment and child engagement, non-verbal communication, travel and familiarity with remote interactions. Parents recognised the influence the physical and online environment had on their child's engagement levels, however, varied in their experience and hence preference of delivery method. All families emphasised the importance of non-verbal communication within DDP sessions and majority highlighted this may be lost online. For families who travelled to face-to-face DDP, car journeys provided a unique opportunity to decompress and reflect after sessions. For families where travel is unfeasible, online DDP was a lifeline, demonstrating the ability of remote therapy to widen access to specialist healthcare. Familiarity with online work emerged as a strong indicator of positive attitudes towards remote DDP, especially if the previous experience is positive and the child is confident using technology. Overall, families differed greatly in their experience of remote and face-to-face DDP indicating a new approach must be undertaken with each family beginning therapy, ensuring it is unique and individual to their needs.

Helping themselves and helping others: how the passage of time influences why mothers with addictions take part in research.

Introduction: Women with addiction issues are under-researched, despite previous evidence that women's needs are less understood than men's and that services can overlook gender-specific issues. The majority of women in treatment are mothers and a significant number have contact with child welfare services. The voices of these women are needed to shape and influence evidence-based treatment and service development. Aim: To examine reasons and rationale for participation in research in mothers with addiction issues and involvement with the child welfare system. Method: Reflexive thematic analysis was used on interview transcripts from two qualitative studies. Individual themes from each study were combined and analysed to develop themes covering both studies and at different timepoints in process of child welfare assessment or removal of child/ren. Results: Three themes were identified (1) altruism; (2) personal benefit; and (3) empowerment. These mothers wanted to help with research. However, they also participated with the hope that this might facilitate the return of their children or help them to access support or services. A change over time was evident and, in those further down the line from child removal, there was a stronger want for their voices to be heard in order to advocate for other women and create change in services.

Using the live assessment to discriminate between Autism Spectrum Disorder and Disinhibited Social Engagement Disorder.

BACKGROUND: Children with Autism Spectrum Disorder (ASD) and children with Disinhibited Social Engagement Disorder (DSED) may present with similar social problems, despite differing aetiologies, resulting in diagnostic conundrums. METHODS: Thirty children: 10 with ASD, no maltreatment history, 10 with DSED and 10 typically developing children were assessed via 'gold standard' ASD assessments, including the Autism Diagnostic Observational Schedule (ADOS) and a unique unstructured observation known as the Live assessment. Live utilises a triadic interaction (2 assessors and child), playful teasing and social 'stress' scenarios to increase the social challenge. RESULTS: The ADOS supported discrimination of DSED from ASD to a degree. Where additional neurodevelopmental problems created ambiguity, the Live assessment was more supportive than the ADOS for unpicking the underlying nature of the social problems. CONCLUSION: Live supported differentiation between ASD, DSED and other neurodevelopmental problems. The greater social challenge presented by Live exacerbated core problems of ASD and, in DSED, core social skills stood out.

"I will commit to this child as much as I can for the time that they are with me:" A qualitative examination of how foster carer commitment relates to short-term foster care for young children following abuse and neglect.

BACKGROUND: Foster carer commitment to the child has been shown to be of paramount importance in young children's recovery and development following abuse and neglect. In Dozier's definition of commitment in the US, there is a focus on both emotional investment in the child and committing to an enduring relationship with the child. How this relates to the routine practice of short-term, temporary, foster care has not been studied. OBJECTIVE: This is the first qualitative study to explore the drivers of, and barriers to, commitment in short-term foster care within the broader aim of examining whether short-term care is meeting the needs of maltreated young children. PARTICIPANTS & SETTING: Fourteen foster carers took part in research interviews and five focus groups were conducted with infant mental health professionals. METHODS: Interviews and focus group data were subject to qualitative thematic analysis in order to identify patterns of commonality in relation to our research questions. RESULTS: Three broad themes pertain to commitment and the meeting of young children's needs in short-term foster care: Influence, Timescales and Choice in the fostering role. These themes were found to house both drivers of, and barriers to, commitment in short-term care, which are influenced by systemic normalisations of fostering practices. CONCLUSIONS: The emotional investment facet of commitment is more alive in the 'psyche' of short-term foster care than commitment to an enduring relationship. A long-term outlook for the child may be an undefined facet of commitment that is more akin with short-term placements.

Gender, Addiction, and Removal of Children Into Care.

Introduction: Parental addiction can result in harm to children and removal of children by the Local Authority. Less is known about the impact of removal of children on their parents and whether gender has a role in this process. Methods: Data on 736 service users were obtained from the caseloads of 8 nurses and 12 social care workers from an Alcohol and Drug Recovery Service in Scotland. Gender differences in prevalence/patterns of child removal, associations between child removal and parental factors and the relationship between removal and suicidality were examined. Results: Mothers were more likely to have had one or more children removed compared to fathers (56.6 vs. 17.7%; p < 0.001) and were more likely to have a series of individual child removals (22.5 vs. 4.3%; p = 0.014). In addition to female gender, younger age, drug use, mental health and suicide attempts were also associated with child removal. Mothers who had children removed and women who were not mothers were more likely to have made an attempt to end their lives than women who had children but had not had them removed. Conclusion: Gender differences were apparent in prevalence and patterns of child removal. Mothers were six times more likely to have children removed compared to fathers. Child removal occurred alongside other risk factors suggesting that families need holistic support for their multiple areas of need. Services should be aware of the link between child removal and suicide and provide additional support to mothers during and after removal.

The expected and the unexpected in recovery and development after abuse and neglect: The role of early foster carer commitment on young children's symptoms of attachment disorders and mental health problems over time.

BACKGROUND: Whilst we know that foster care is better than institutional care for abused and neglected children, we know less about the specific qualities of foster care that are important for their development and recovery from maltreatment effects. OBJECTIVE: This is the first study to investigate the effects of foster carer commitment on symptoms of Attachment Disorders (AD) and mental health problems in young children post-maltreatment. PARTICIPANTS & SETTING: 144 children, age 0-5, recently accommodated into foster care as part of an ongoing Randomised Controlled Trial. METHODS: Children were assessed using the Disturbances of Attachment Interview and the Strengths and Difficulties Questionnaire, then followed up 15 months and 2.5 years thereafter. Commitment of the foster carer was measured by 'This Is My Baby' interview. Multiple regression was used to analyse the data. RESULTS: Higher initial foster carer commitment, measured shortly after entry to care, was associated with a reduction in Reactive Attachment Disorder symptoms 15 months after placement, with a modest (non-significant) association persisting 2.5 years later. Initial commitment was not associated with symptoms of Disinhibited Social Engagement Disorder at any follow-up time point, nor with symptoms of mental health problems at 15 months. However, higher initial commitment was unexpectedly associated with higher mental health symptom scores at 2.5 years post-accommodation. CONCLUSIONS: This study highlights the complex and non-linear development of children in committed foster care, underscoring the need to examine multiple time-points and to consider symptoms of Attachment Disorders separately from those of other mental health problems.

Projected land ice contributions to twenty-first-century sea level rise.

The land ice contribution to global mean sea level rise has not yet been predicted1 using ice sheet and glacier models for the latest set of socio-economic scenarios, nor using coordinated exploration of uncertainties arising from the various computer models involved. Two recent international projects generated a large suite of projections using multiple models2-8, but primarily used previous-generation scenarios9 and climate models10, and could not fully explore known uncertainties. Here we estimate probability distributions for these projections under the new scenarios11,12 using statistical emulation of the ice sheet and glacier models. We find that limiting global warming to 1.5 degrees Celsius would halve the land ice contribution to twenty-first-century sea level rise, relative to current emissions pledges. The median decreases from 25 to 13 centimetres sea level equivalent (SLE) by 2100, with glaciers responsible for half the sea level contribution. The projected Antarctic contribution does not show a clear response to the emissions scenario, owing to uncertainties in the competing processes of increasing ice loss and snowfall accumulation in a warming climate. However, under risk-averse (pessimistic) assumptions, Antarctic ice loss could be five times higher, increasing the median land ice contribution to 42 centimetres SLE under current policies and pledges, with the 95th percentile projection exceeding half a metre even under 1.5 degrees Celsius warming. This would severely limit the possibility of mitigating future coastal flooding. Given this large range (between 13 centimetres SLE using the main projections under 1.5 degrees Celsius warming and 42 centimetres SLE using risk-averse projections under current pledges), adaptation planning for twenty-first-century sea level rise must account for a factor-of-three uncertainty in the land ice contribution until climate policies and the Antarctic response are further constrained.

A feasibility randomised controlled trial of the New Orleans intervention for infant mental health: a study protocol.

Child maltreatment is associated with life-long social, physical, and mental health problems. Intervening early to provide maltreated children with safe, nurturing care can improve outcomes. The need for prompt decisions about permanent placement (i.e., regarding adoption or return home) is internationally recognised. However, a recent Glasgow audit showed that many maltreated children "revolve" between birth families and foster carers. This paper describes the protocol of the first exploratory randomised controlled trial of a mental health intervention aimed at improving placement permanency decisions for maltreated children. This trial compares an infant's mental health intervention with the new enhanced service as usual for maltreated children entering care in Glasgow. As both are new services, the trial is being conducted from a position of equipoise. The outcome assessment covers various fields of a child's neurodevelopment to identify problems in any ESSENCE domain. The feasibility, reliability, and developmental appropriateness of all outcome measures are examined. Additionally, the potential for linkage with routinely collected data on health and social care and, in the future, education is explored. The results will inform a definitive randomised controlled trial that could potentially lead to long lasting benefits for the Scottish population and which may be applicable to other areas of the world. This trial is registered with ClinicalTrials.gov (NC01485510).

Delivering a national programme of anticipatory care in primary care: a qualitative study.

BACKGROUND: Primary prevention often occurs against a background of inequalities in health and health care. Addressing this requires practitioners and systems to acknowledge the contribution of health-related and social determinants and to deal with the lack of interconnectedness between health and social service providers. Recognising this, the Scottish Government has implemented a national programme of anticipatory care targeting individuals aged 45-64 years living in areas of socioeconomic deprivation and at high risk of cardiovascular disease. This programme is called Keep Well. AIM: To explore the issues and tensions underpinning the implementation of a national programme of anticipatory care. DESIGN AND SETTING: A qualitative study in five Wave 1 Keep Well pilot sites, located in urban areas of Scotland, and involving 79 general practices. METHOD: Annual semi-structured interviews were conducted with 74 key stakeholders operating at national government level, local pilot level and within general practices, resulting in 118 interviews. Interview transcripts were analysed using the framework approach. RESULTS: Four underlying tensions were identified. First, those between a patient-focused general-practice approach versus a population-level health-improvement approach, linking disparate health and social services; secondly, medical approaches versus wider social approaches; thirdly, a population-wide approach versus individual targeting; and finally, reactive versus anticipatory care. CONCLUSION: Implementing an anticipatory care programme to address inequalities in cardiovascular disease identified several tensions, which need to be understood and resolved in order to inform the development of such approaches in general practice and to develop systems that reduce the degree of fragmentation across health and social services.

What is the 'problem' that outreach work seeks to address and how might it be tackled? Seeking theory in a primary health prevention programme.

BACKGROUND: Preventive approaches to health are disproportionately accessed by the more affluent and recent health improvement policy advocates the use of targeted preventive primary care to reduce risk factors in poorer individuals and communities. Outreach has become part of the health service response. Outreach has a long history of engaging those who do not otherwise access services. It has, however, been described as eclectic in its purpose, clientele and mode of practice; its effectiveness is unproven.Using a primary prevention programme in the UK as a case, this paper addresses two research questions: what are the perceived problems of non-engagement that outreach aims to address; and, what specific mechanisms of outreach are hypothesised to tackle these. METHODS: Drawing on a wider programme evaluation, the study undertook qualitative interviews with strategically selected health-care professionals. The analysis was thematically guided by the concept of 'candidacy' which theorises the dynamic process through which services and individuals negotiate appropriate service use. RESULTS: The study identified seven types of engagement 'problem' and corresponding solutions. These 'problems' lie on a continuum of complexity in terms of the challenges they present to primary care. Reasons for non-engagement are congruent with the concept of 'candidacy' but point to ways in which it can be expanded. CONCLUSIONS: The paper draws conclusions about the role of outreach in contributing to the implementation of inequalities focused primary prevention and identifies further research needed in the theoretical development of both outreach as an approach and candidacy as a conceptual framework.

Functional outcome following liver transplantation - a pilot study.

BACKGROUND/AIMS: We have previously shown that prior to liver transplantation, patients exhibit impairment in memory and psychomotor speed. Despite significant improvement following transplantation, recovery remained incomplete at 1 year post-transplant. This study aimed to investigate the effects of liver transplantation on a wider range of cognitive abilities, and to assess the impact of any impairment upon day-to-day functioning, particularly driving ability. METHODS: This study was a between-group design involving three groups of participants: liver transplant candidates, liver transplant recipients and healthy controls. All participants completed measures of affective status, functional capacity, quality of life, neuropsychological status and driving ability. RESULTS: For the majority of measures, healthy controls performed best, followed by liver transplant recipients and then liver transplant candidates, respectively. This pattern was most pronounced with respect to functional limitations, language and attention. No significant difference between the three groups was observed for simulated driving ability. CONCLUSIONS: The results suggest that while significant recovery occurs in many areas of psychosocial functioning following liver transplantation, this recovery may be incomplete, that is, many patients do not recover to their full pre-illness status. The measure we employed to assess driving ability was not a sensitive or discriminating measure in this study.

Sialosis: 35 cases of persistent parotid swelling from two countries.

Diffuse, non-inflammatory, non-neoplastic enlargement of the major salivary glands (sialosis) is uncommon and has various systemic causes. This paper examines 35 patients whose persistent swelling of the parotid was diagnosed as sialosis, and shows that diabetes mellitus and alcoholism are the most common causes.

A mouse gene that coordinates epigenetic controls and transcriptional interference to achieve tissue-specific expression.

The mouse fpgs gene uses two distantly placed promoters to produce functionally distinct isozymes in a tissue-specific pattern. We queried how the P1 and P2 promoters were differentially controlled. DNA methylation of the CpG-sparse P1 promoter occurred only in tissues not initiating transcription at this site. The P2 promoter, which was embedded in a CpG island, appeared open to transcription in all tissues by several criteria, including lack of DNA methylation, yet was used only in dividing tissues. The patterns of histone modifications over the two promoters were very different: over P1, histone activation marks (acetylated histones H3 and H4 and H3 trimethylated at K4) reflected transcriptional activity and apparently reinforced the effects of hypomethylated CpGs; over P2, these marks were present in tissues whether P2 was active, inactive, or engaged in assembly of futile initiation complexes. Since P1 transcriptional activity coexisted with silencing of P2, we sought the mechanism of this transcriptional interference. We found RNA polymerase II, phosphorylated in a pattern consistent with transcriptional elongation, and only minimal levels of initiation factors over P2 in liver. We concluded that mouse fpgs uses DNA methylation to control tissue-specific expression from a CpG-sparse promoter, which is dominant over a downstream promoter masked by promoter occlusion.

Chromatin immunoprecipitation assay for mammalian tissues.

In this postgenome era, understanding how a cell regulates access to information encoded in the deoxyribonucleic acid (DNA) is essential. In eukaryotic cells, DNA is bound to histone proteins to form chromatin fibers. Numerous studies have now shown that post-translational histone modifications play an important role in regulating the access of DNA-dependent proteins to the DNA template. Determining the status of histone modifications in a genomic region has proven to yield information on the chromatin structure and the regulation of a specific gene in vivo. Chromatin immunoprecipitation (ChIP) allows researchers to determine the status of both histone modifications and the nuclear effector proteins located at gene of interest. ChIP, if applied globally, can also reveal how chromatin structures are dynamically changed when cells respond to certain stimuli. In this chapter, we describe this powerful technique in detail.

Modifications of human histone H3 variants during mitosis.

Phosphorylation of histone H3 is a hallmark event in mitosis and is associated with chromosome condensation. Here, we use a combination of immobilized metal affinity chromatography and tandem mass spectrometry to characterize post-translational modifications associated with phosphorylation on the N-terminal tails of histone H3 variants purified from mitotically arrested HeLa cells. Modifications observed in vivo on lysine residues adjacent to phosphorylated Ser and Thr provide support for the existence of the "methyl/phos", binary-switch hypothesis [Fischle, W., Wang, Y., and Allis, C. D. (2003) Nature 425, 475-479]. ELISA with antibodies selective for H3 at Ser10, Ser28, and Thr3 show reduced activity when adjacent Lys residues are modified. When used together, mass spectrometry and immunoassay methods provide a powerful approach for elucidation of the histone code and identification of histone post-translational modifications that occur during mitosis and other specific cellular events.

Phosphorylation of histone H4 serine 1 during DNA damage requires casein kinase II in S. cerevisiae.

Distinct patterns of posttranslational histone modifications can regulate DNA-templated events such as mitosis, transcription, replication, apoptosis, and DNA damage, suggesting the presence of a "histone code" in these nuclear processes. Phosphorylation of histone H2A S129 at sites of DNA double-strand breaks (DSBs) has been implicated in damage repair in yeast. Here, we describe another phosphorylation event on serine 1 (S1) of histone H4; this event is also associated with MMS- or phleomycin-induced DSBs but not with UV-induced DNA damage. Chromatin-immunoprecipitation (ChIP) studies of an HO-endonuclease-inducible strain show that S1 phosphorylation is specifically enhanced 20- to 25-fold in nucleosomes proximal to the DSB. In addition, we show that casein kinase II (CK2) can phosphorylate H4 S1 in vitro and that null or temperature-sensitive CK2 yeast mutants are defective for induction of H4 S1 phosphorylation upon DNA damage in vivo. Furthermore, H4 S1 phosphorylation and CK2 play a role in DSB re-joining as indicated by a nonhomologous end-joining (NHEJ) plasmid assay. CK2 has been implicated in regulating a DNA-damage response; our data suggest that histone H4 S1 is one of its physiological substrates. These data suggest that this modification is a part of the DNA-repair histone code.

The enhancement of histone H4 and H2A serine 1 phosphorylation during mitosis and S-phase is evolutionarily conserved.

Histone phosphorylation has long been associated with condensed mitotic chromatin; however, the functional roles of these modifications are not yet understood. Histones H1 and H3 are highly phosphorylated from late G2 through telophase in many organisms, and have been implicated in chromatin condensation and sister chromatid segregation. However, mutational analyses in yeast and biochemical experiments with Xenopus extracts have demonstrated that phosphorylation of H1 and H3 is not essential for such processes. In this study, we investigated additional histone phosphorylation events that may have redundant functions to H1 and H3 phosphorylation during mitosis. We developed an antibody to H4 and H2A that are phosphorylated at their respective serine 1 (S1) residues and found that H4S1/H2AS1 are highly phosphorylated in the mitotic chromatin of worm, fly, and mammals. Mitotic H4/H2A phosphorylation has similar timing and localization as H3 phosphorylation, and closely correlates with the chromatin condensation events during mitosis. We also detected a lower level of H4/H2A phosphorylation in 5-bromo-2-deoxyuridine-positive S-phase cells, which corroborates earlier studies that identified H4S1 phosphorylation on newly synthesized histones during S-phase. The evolutionarily conserved phosphorylation of H4/H2A during the cell cycle suggests that they may have a dual purpose in chromatin condensation during mitosis and histone deposition during S-phase.