Replicating Evidence-Based Practices with Flexibility for Perinatal Home Visiting by Paraprofessionals.

Introduction Strategies are needed to improve the efficacy of paraprofessional home visitors for pregnant women in the United States. This study evaluates the maternal and child outcomes when evidence-based practices (EBP) are replicated with flexibility, rather than fidelity to a manualized intervention. Methods Pregnant mothers (N = 203) in five clinics were recruited in the waiting rooms and randomized to standard clinic care as the control condition (n = 104) or standard care plus home visiting (n = 99). Home visitors (n = 9) were selected, trained in foundational skills common to EBP and four problem domains (weight control, breastfeeding, daily habits, and depression). Independent interviewers assessed targeted outcomes at birth (82%) and 6 months later (83%). RESULTS: Home visitors, called Mentor Mothers [MM], made an average of 14.9 home visits or telephone contacts (SD = 9; total contacts = 1491) addressing maternal daily habits, breastfeeding, and depression. Intervention and control mothers were similar in weight, Body Mass Index (BMI), depression and social support at baseline and 6 months later. The percentage of low birth weight babies was similar; intervention infants' growth (weight/height Z score) tended to be significantly better compared to the control condition. DISCUSSION: There are many explanations for the failure to find significant benefits: insufficient statistical power; the benefits of repeated assessments by warm, supportive peers to improve outcomes; or the failure of EBP and the need to maintain replication with fidelity. All study mothers had better outcomes than documented among comparable published samples of low-income, Latina and Korean-American mothers in Los Angeles, CA. ClinicalTrials.gov registration NCT01687634.

Adapting Current Strategies to Implement Evidence-Based Prevention Programs for Paraprofessional Home Visiting.

This paper describes a strategy for using evidence-based interventions (EBI) that does not require replication and fidelity. Eight parents, identified as positive role models, conducted home visits for 101 low-income Latina and Korean pregnant women. The home visitors, called mentor mothers (MM), were trained in 10 of the practice elements common to 80% of child-focused EBI and how to apply these skills to support mothers in obesity prevention, to increase the duration of breastfeeding, and to reduce depression. MM reported the content and skills utilized on each home visit on mobile phones. Each MM made an average of 153 home visits (SD = 173.3), with 28 of these visits being phone contacts. Body mass index (BMI) at 6 months was significantly associated with the frequency of MM focused on coping with depression (r = .24), but was not related to practice elements used by MM. The duration of breastfeeding was significantly related to the frequency with which MM focused on the topic of breastfeeding (r = .28) and parenting (r = .3), and MM use of attending (r = .24) and relaxation (r = .27). Depression was significantly correlated with the frequency of addressing depression (r = .27), but not to practice elements. MM did use different strategies in the first 150 visits compared to their last 150 visits, reflecting data-informed supervision. Evidence synthesized from EBI was used as a novel training method, with real-time monitoring and data-informed supervision providing evidence of iterative quality improvements in MM behaviors over time, as well as a way for linking implementation processes to outcomes.

Making the connection: randomized controlled trial of social skills at school for children with autism spectrum disorders.

BACKGROUND: This study compared two interventions for improving the social skills of high functioning children with autism spectrum disorders in general education classrooms. One intervention involved a peer-mediated approach (PEER) and the other involved a child-assisted approach (CHILD). METHOD: The two interventions were crossed in a 2 × 2 factorial design yielding control, PEER, CHILD, and both PEER and CHILD conditions. Sixty children participated from 56 classrooms in 30 schools. Interventions involved 12 sessions over 6 weeks, with a 3-month follow-up. Outcome measures included self, peer and teacher reports of social skills and independent weekly observations of children on their school playground over the course of the intervention. RESULTS: Significant improvements were found in social network salience, number of friendship nominations, teacher report of social skills in the classroom, and decreased isolation on the playground for children who received PEER interventions. Changes obtained at the end of the treatment persisted to the 3-month follow-up. CONCLUSIONS: These data suggest that significant improvements can be made in peer social connections for children with autism spectrum disorders in general education classrooms with a brief intervention, and that these gains persist over time.

Maternal depressed mood and child development over the first five years of life in South Africa.

BACKGROUND: While the negative impact of peri-natal depression is well-documented in high-income countries, the long-term effects across the life course in low and middle-income countries is less clear. Children's adjustment over the first five years is examined as a function of patterns of maternal depressed mood. METHODS: Pregnant women in 24 peri-urban townships (N = 1,238) were randomized to a home-visiting intervention or standard care and reassessed five times, with high retention. There were no intervention effects on children past 18 months. Multilevel regression models examined the impact of depressed mood on child outcomes. Using the Edinburgh Postnatal Depression Scale, four patterns of maternal depressed mood were identified: never (40.6%); antenatal (13.0%); early childhood (26.1%); and recurrent episodes of depressed mood (20.3 %). FINDINGS: Mothers' patterns of depressive symptoms and child outcomes were similar, regardless of intervention. Never depressed mothers were significantly younger, had higher income, less food insecurity, were more likely to have electricity, be living with HIV or have an HIV positive partner, and had fewer problems with alcohol than depressed mothers. Children of mothers who experienced depressed mood weighed less, were more aggressive, and were hospitalized more often than children of never depressed mothers, but were similar in cognitive and social development. INTERPRETATIONS: Depressed mood, has significant negative impacts on South African children's growth and aggressive behavior. The timing of maternal depressed mood was less important than never having a depressed mood or a recurrent depressed mood. FUNDING: There were no funding conflicts in executing this trial.

Social involvement of children with autism spectrum disorders in elementary school classrooms.

BACKGROUND: Children with autism spectrum disorders (ASD) are increasingly included in general education classrooms in an effort to improve their social involvement. METHODS: Seventy-nine children with ASD and 79 randomly selected, gender-matched peers (88.6% male) in 75 early (K-1), middle (2nd-3rd), and late (4th-5th) elementary classrooms across 30 schools completed social network surveys examining each child's reciprocal friendships, peer rejection, acceptance, and social involvement. RESULTS: Across grade levels, peers less frequently reciprocated friendships with children with ASD than students in the matched sample. While children with ASD were not more likely to be rejected by peers, they were less accepted and had fewer reciprocal friendships than matched peers at each grade level. Although 48.1% of children with ASD were involved in the social networks of their classrooms, children with ASD were more likely to be isolated or peripheral to social relationships within the classroom across all grade levels, and this difference is even more dramatic in later elementary grades. CONCLUSIONS: In inclusive classrooms, children with ASD are only involved in peers' social relationships about half of the time, and appear to be even less connected with increasing grade level. Promoting children with ASD's skills in popular activities to share with peers in early childhood may be a key preventive intervention to protect social relationships in late elementary school grades.

Comparing a Practice-Based Model with a Research-Based Model of social skills interventions for children with autism in schools.

Background: Social impairment is the most challenging core deficit for children with autism spectrum disorder (ASD). Several evidence-based interventions address social impairment in children with ASD; however, adoption, use, and implementation of these interventions in schools is challenging. Method: Ninety-two children with ASD who received one of three intervention models: a) School personnel adapted and implemented evidence-based social skills intervention (Practice-Based Model; n = 14); b) University researcher developed and implemented evidence-based social skills intervention (Research-Based Model; n = 45); or c) standard educational practices model (Inclusion Only Model; n = 33) participated. The average age was 8.4 (SD = 1.6) years; majority was male (88%) and white (52.2%). Typically developing classmates completed sociometric ratings to determine children's social network inclusion, and independent raters observed children on the playground using a time-interval behavior coding system to record solitary engagement and frequency of initiations. Results: Separate linear regression models were conducted. Children in the Research-Based Model had significantly higher social network inclusion than children in the other two settings (p = .05). Children in the Practice-Based Model had significantly lower solitary engagement (p = .04) and more initiations on the playground than children in the University Developed Model (p = .04). Conclusions: The results suggest that researchers: 1) may learn from public school stakeholders who have lived experiences to better understand the context in which implementation occurs; and 2) should partner with schools to learn about their processes of adaptation and adoption in order to facilitate successful implementation of evidence-based practices for children with ASD. Interventions designed with implementation in mind may be more feasible and increase the chances of use in schools.

Randomized, placebo-controlled trial of bupropion for the treatment of methamphetamine dependence.

OBJECTIVE: To compare bupropion to placebo for reducing methamphetamine (MA) use, increasing retention, and reducing the severity of depressive symptoms and MA-cravings. A secondary objective compared bupropion to placebo for reducing cigarette smoking among MA dependent participants. METHODS: Following a 2-week, non-medication baseline screening period, 73 treatment-seeking MA dependent participants were randomly assigned to bupropion sustained release (150 mg twice daily; N=36) or placebo (twice daily; N=37) for 12-weeks under double-blind conditions. Participants attended clinic thrice weekly to provide urine samples analyzed for MA-metabolite, to complete research measures and assessments, and to receive contingency management and weekly cognitive behavioral therapy sessions. RESULTS: There were no statistically significant effects for bupropion relative to placebo on MA use verified by urine drug screens, for reducing the severity of depressive symptoms or MA-cravings, or on study retention. In a post hoc analysis, there was a statistically significant effect of bupropion treatment on MA use among participants with lighter (0-2 MA-positive urines), but not heavier (3-6 MA-positive urines) MA use during baseline (OR=2.81, 95% CI=1.61-4.93, p<0.001 for MA-free week with bupropion among light users). Bupropion treatment was also associated with significantly reduced cigarette smoking, by almost five cigarettes per day (p=0.0002). CONCLUSION: Bupropion was no more effective than placebo in reducing MA use in planned analyses, though bupropion did reduce cigarette smoking. Post hoc findings of an effect for bupropion among baseline light, but not heavy, MA users suggests further evaluation of bupropion for light-MA users is warranted.

Bupropion hydrochloride versus placebo, in combination with cognitive behavioral therapy, for the treatment of cocaine abuse/dependence.

Bupropion hydrochloride is a dopamine and norepinephrine reuptake inhibitor which may be an effective treatment for cocaine dependence due to its ability to reverse deficits in dopaminergic functioning that occur in chronic cocaine users. We performed a randomized, double-blind, placebo controlled trial comparing outpatient treatment with bupropion (N = 37) and placebo (N = 33) in combination with standard cognitive behavioral therapy. There were no statistically significant differences between bupropion and placebo in treatment outcomes, including aggregate measures of urine drug screen results (Joint Probability Index at 16 weeks: 0.43 for bupropion and 0.38 for placebo), treatment retention, cocaine craving ratings, and assessments of depressive symptoms. The failure to find an effect for bupropion relative to placebo, when combined with standard cognitive behavioral therapy, dampens enthusiasm for future development of bupropion as a cocaine pharmacotherapy.

Family Coaching as a delivery modality for evidence-based prevention programs.

Family Coaching is proposed as a new delivery format for evidence-based prevention programs (EBPPs). Three recent developments in health promotion support the potential efficacy of Family Coaching: (1) renewed interest in integrated prevention programs for multiple risk factors and behavior changes, (2) broad and long-term impacts of family-based interventions, and (3) popular acceptance of "coaching" as a nonstigmatizing, goal-focused intervention strategy. Family coaches are community members and paraprofessionals trained in common elements of EBPP. Family Coaching has specific goals, is short term, and has definable outcomes. Coaches frame the program's goals to be consistent with the family's values, normalize the family's experience, assess their strengths, and help the family set goals and develop skills and routines to problem solve challenging situations. Broad dissemination of EBPP will be facilitated with delivery formats that are flexible to meet families' priorities and providers' desires and capacities to tailor programs to local contexts.

Maternal patterns of antenatal and postnatal depressed mood and the impact on child health at 3-years postpartum.

OBJECTIVE: The consequences of maternal depressed mood on children's growth, health, and cognitive and language development are examined over the first 3 years of life. METHOD: Pregnant women in 24 periurban township neighborhoods in Cape Town, South Africa (N = 1,238 mothers) were randomized by neighborhood to a home visiting intervention or a standard care condition. Reassessments were conducted for 93%-85% of mothers at 2-weeks, 6-, 18-, and 36-months postbirth. Regressions were conducted on measures of children's growth, behavior, language, and cognition to examine the impact of four patterns of depressed mood: antenatal only (n = 154, 13.8%), postnatal only (n = 272, 24.3%), antenatal and postnatal (n = 220, 19.7%), and no depressed mood on any assessment (n = 473, 42.3%). RESULTS: Patterns of depressed mood were similar across intervention conditions. Depressed mothers were significantly less educated, had lower incomes, were less likely to be employed or to have electricity; were more likely to report problematic drinking of alcohol, experience food insecurity, interpersonal partner violence, and to be HIV seropositive. At 36 months, the pattern of maternal depressed mood over time was significantly associated with children's compromised physical growth, both in weight and height, and more internalizing and externalizing symptoms of behavior problems. Measures of language and cognition were similar across maternal patterns of depressed mood. CONCLUSIONS: Mothers who report depressed mood face significantly more life challenges, both environmental stressors related to poverty and other problematic behaviors. More proximal, postnatal depressed mood appears to have a larger influence on their children, compared with antenatal depressed mood. (PsycINFO Database Record

Involvement or isolation? The social networks of children with autism in regular classrooms.

Including children with autism in regular classrooms has become prevalent; yet some evidence suggests such placements could increase the risk of isolation and rejection. In this study, we used social network methods to explore the involvement of children with autism in typical classrooms. Participants were 398 children (196 boys) in regular 2nd through 5th grade classes, including 17 children (14 boys) with high functioning autism or Asperger's syndrome. Children reported on friendship qualities, peer acceptance, loneliness, and classroom social networks. Despite involvement in networks, children with autism experienced lower centrality, acceptance, companionship, and reciprocity; yet they did not report greater loneliness. Future research is needed to help children with autism move from the periphery to more effective engagement with peers.

Subjective and cardiovascular effects of cocaine during treatment with amantadine and baclofen in combination.

This study assessed the subjective and cardiovascular effects of relevant doses of cocaine administration during steady-state treatment of the combination of amantadine and baclofen compared to placebo. Participants included 8 healthy, male, cocaine-dependent, non-treatment-seeking individuals (age=36.6+/-5.9; 75% African American, 25% Caucasian; using cocaine for an average of 15.3+/-6.5 years). Data were collected prior to and following double-blind intravenous administration of 0 mg, 20 mg, and 40 mg of cocaine. Data were collected at baseline, following 5 days of treatment with placebo, and again following 5 days of treatment with a combination of amantadine 100 mg t.i.d. and baclofen 30 mg t.i.d. counterbalanced for order of medication and placebo in a cross-over design. Results showed no significant alterations to cardiovascular variables (heart rate, systolic and diastolic blood pressure) from treatment using combination medication or placebo in the presence of cocaine. Self-rated "desire" for cocaine was significantly lower during cocaine administrations while participants were receiving treatment with amantadine-baclofen compared to infusions while taking placebo medication, although there was no difference in the intensity of cocaine-induced euphoria, or reduction in the likelihood to use cocaine if given access. Study findings support the safety of the amantadine-baclofen combination treatment for cocaine dependence.

Depression ratings, reported sexual risk behaviors, and methamphetamine use: latent growth curve models of positive change among gay and bisexual men in an outpatient treatment program.

Although the cessation of substance use is the principal concern of drug treatment programs, many individuals in treatment experience co-occurring problems such as mood disruptions and sexual risk behaviors that may complicate their recovery process. This study assessed relationships among dynamic changes tracked over time in methamphetamine use, depression symptoms, and sexual risk behaviors (unprotected anal intercourse) in a sample of 145 methamphetamine-dependent gay and bisexual males enrolled in a 16-week outpatient drug treatment research program. Participants were randomly assigned into 1 of 4 conditions: contingency management (CM), cognitive behavioral therapy (CBT; the control condition), combined CM and CBT, and a tailored gay-specific version of the CBT condition. Using latent growth curve models, the authors assessed the relationship of means (intercepts) and the slopes of the 3 measures of interest over time to test whether changes in methamphetamine use predicted declining rates of depression and risky sexual behavior in tandem. Participants with the greatest downward trajectory in methamphetamine use (urine verified) reported the greatest and quickest decreases in reported depressive symptoms and sexual risk behaviors. The control group reported the most methamphetamine use over the 16 weeks; the tailored gay-specific group reported a more rapidly decreasing slope in methamphetamine use than the other participants. Findings indicate that lowering methamphetamine use itself has a concurrent and synergistic effect on depressive symptoms and risky sexual behavior patterns. This suggests that some users who respond well to treatment may show improvement in these co-occurring problems without a need for more intensive targeted interventions.

Brief Report: Examining Executive and Social Functioning in Elementary-Aged Children with Autism.

There is a paucity of literature examining the relationship between executive and social functioning in children with autism spectrum disorder (ASD). Twenty-three school-aged children with ASD participated. Executive functioning was measured using the Developmental Neuropsychological Assessment, Second Edition and Differential Ability Scales, Second Edition, and the teacher-rated Behavior Rating of Inventory of Executive Function. Independent assessors observed children's social functioning on the playground while children with ASD and their peers completed a survey to measure peer friendships and rejections. Overall, poorer executive functioning was associated with increased playground isolation and less engagement with peers. This suggests that metacognitive skills such as initiation, working memory, and planning and organization are associated with children's social functioning.

Randomized, placebo-controlled trial of sertraline and contingency management for the treatment of methamphetamine dependence.

BACKGROUND: Methamphetamine dependence and associated medical and psychiatric concerns are significant public health issues. This project evaluated the efficacy of sertraline (50mg bid) and contingency management (CM) for the treatment of methamphetamine dependence. METHOD: In this randomized, placebo-controlled, double-blind trial, participants completed a 2-week non-medication baseline and were randomized to one of four conditions for 12 weeks: sertraline plus CM (n=61), sertraline-only (n=59), matching placebo plus CM (n=54), or matching placebo-only (n=55). All participants attended clinic thrice-weekly for data collection, medication dispensing, and relapse prevention groups. Outcomes included methamphetamine use (urine drug screening and self-reported days of use), retention (length of stay), drug craving (visual analogue scale), and mood symptoms (Beck Depression Inventory). RESULTS: No statistically significant main or interaction effects for sertraline or CM in reducing methamphetamine use were observed using a generalized estimating equation (GEE), although post hoc analyses showed the sertraline-only condition had significantly poorer retention than other conditions (chi(2) (3)=8.40, p<0.05). Sertraline conditions produced significantly more adverse events than placebo conditions. A significantly higher proportion of participants in CM conditions achieved three consecutive weeks of methamphetamine abstinence than those in non-CM conditions. CONCLUSIONS: These data do not demonstrate improved outcomes for sertraline versus placebo for treatment of methamphetamine dependence; indeed, they suggest sertraline is contraindicated for methamphetamine dependence. Findings provide support for the use of contingency management for treatment of methamphetamine dependence.

Behavioral treatment approaches for methamphetamine dependence and HIV-related sexual risk behaviors among urban gay and bisexual men.

BACKGROUND: Methamphetamine-dependent gay and bisexual men (GBM) are at high risk for HIV transmission, largely due to drug-associated sexual risk behaviors. This project evaluated the efficacy of four behavioral drug abuse treatments for reducing methamphetamine use and sexual risk behaviors among this population. METHODS: In this randomized controlled trial, 162 methamphetamine-dependent (SCID-verified) GBM in Los Angeles County were randomly assigned to one of four treatment conditions for 16 weeks: standard cognitive behavioral therapy (CBT, n=40), contingency management (CM, n=42), combined cognitive behavioral therapy and contingency management (CBT+CM, n=40), and a culturally tailored cognitive behavioral therapy (GCBT, n=40). Stimulant use was assessed thrice-weekly during treatment using urine drug screens (48 measures). Sexual risk behaviors were monitored monthly (four measures). Follow-up assessments were conducted at 6 (80.0%) and 12 months (79.9%). RESULTS: Statistically significant differences in retention (F(3,158)=3.78, p<.02), in longest period of consecutive urine samples negative for methamphetamine metabolites (F(3,158)=11.80, p<.001), and in the Treatment Effectiveness Score were observed by condition during treatment (F(3,158)=7.35, p<.001) with post hoc analyses showing the CM and CBT+CM conditions to perform better than standard CBT. GEE modeling results showed GCBT significantly reduced unprotected receptive anal intercourse (URAI) during the first 4 weeks of treatment (X2=6.75, p<.01). During treatment between-group differences disappeared at follow-up with overall reductions in outcomes sustained to 1-year. CONCLUSIONS: Among high-risk methamphetamine-dependent GBM, drug abuse treatments produced significant reductions in methamphetamine use and sexual risk behaviors. Drug abuse treatments merit consideration as a primary HIV prevention strategy for this population.

HIV-associated medical, behavioral, and psychiatric characteristics of treatment-seeking, methamphetamine-dependent men who have sex with men.

This paper examines medical and psychiatric symptoms and disorders associated with reported HIV serostatus among methamphetamine-dependent, treatment-seeking men who have sex with men (MSM) in Los Angeles. Baseline data from a NIDA-funded, randomized clinical trial of behavioral drug abuse therapies included medical examinations and behavioral interviews of the 162 randomized participants. Variables identified as significantly associated with HIV infection were entered into a multivariate, hierarchical logistic regression analysis to optimally predict HIV serostatus. The disturbingly high 61% of the sample with reported HIV-seropositive status represents 3-4 times the prevalence for all MSM in Los Angeles County. HIV infection status strongly associated with prior treatment for methamphetamine dependence; unprotected receptive anal intercourse; history of sexually transmitted infections; and health insurance status. Findings demonstrate the powerful connection between methamphetamine dependence and HIV infection, and strongly suggest a need for development of interventions that function as both substance abuse treatment and HIV prevention for this population.

Current trends in psychological research on children with high-functioning autism and Asperger disorder.

PURPOSE OF REVIEW: This review explores current trends in the literature during 2004 on psychological studies of children with high-functioning autism and Asperger syndrome. Studies are reviewed that examine diagnostic dilemmas and methodological concerns, cognitive and social deficits, and interventions. RECENT FINDINGS: There is considerable debate over the distinction between high-functioning autism and Asperger syndrome, but few studies find support for separate disorders. Most studies reviewed combine high-functioning autism and Asperger syndrome into an autism spectrum disorder group or study only one diagnostic group, either high-functioning autism or Asperger syndrome. Research into cognitive processes (specifically mentalizing) and social understanding (nonliteral language) continue to dominate research efforts. Current studies suggest specific weaknesses in many areas of nonliteral language, such as humor, irony, and teasing. Studies rely heavily on current theoretical explanations for deficits, namely the central coherence, social inference, and executive function theories, and varying levels of support were found for all three theories. Intervention and outcome studies lag behind experimental and theoretical studies, but two studies employed scientifically rigorous intervention designs with promising results. SUMMARY: Children with high-functioning autism and Asperger syndrome have a great deal of potential with respect to long-term developmental outcomes, and yet they continue to be understudied and under-served in current intervention programs. Future studies are needed in developmental processes and outcomes in this population, and in the development of effective treatment strategies that have undergone scientifically rigorous testing.

Randomized placebo-controlled trial of baclofen for cocaine dependence: preliminary effects for individuals with chronic patterns of cocaine use.

BACKGROUND: This screening trial evaluated whether the GABAB agonist baclofen demonstrated sufficient clinical efficacy to recommend an adequately powered trial of the medication as a pharmacotherapy for cocaine dependence. METHOD: Participants with cocaine dependence verified by the Structured Clinical Interview for DSM-IV were randomly assigned to baclofen (N = 35; 20 mg t.i.d.) or placebo conditions (N = 35; identical in appearance and dosage rate) using a 2-group, experimental, 16-week double-blind design featuring thrice-weekly cognitive-behavioral drug counseling groups. Outcomes were retention, cocaine use, cocaine craving, and adverse events. RESULTS: A generalized estimating equation (GEE) model showed that participants assigned to receive baclofen demonstrated statistically significant reductions in cocaine use over those assigned to receive placebo as indicated by urine drug screening results (chi(2) = 5.34, df = 1, p =.021). Confirming the GEE model, longitudinal analyses showed that participants assigned to receive baclofen demonstrated significant and stepwise increases in the probability of providing benzoylecgonine-free urine samples throughout the trial as the number of benzoylecgonine-positive samples increased during baseline (chi(2) = 10.63, df = 1, p =.001). Participants assigned to placebo demonstrated no such association. Univariate analyses of aggregates of urine drug screening showed generally favorable outcomes for baclofen, but not at statistically significant levels. There was no statistical significance observed for retention, cocaine craving, or incidence of reported adverse events by treatment condition. CONCLUSIONS: Project findings demonstrated initial clinical efficacy of baclofen over placebo in reducing cocaine use when delivered concurrent with thrice-weekly drug abuse counseling sessions. The effects of baclofen were particularly apparent for those participants with chronic levels of cocaine use at baseline and provide support for a full-scale efficacy trial for baclofen, especially among this subgroup of patients.