Trauma-informed care in geriatric inpatient units to improve staff skills and reduce patient distress: a co-designed study protocol.

BACKGROUND: Geriatric hospital wards are highly medicalised environments with limited opportunities for choice and control, and can be distressing for older survivors of psychological trauma. While trauma-informed models of care (TIC) are effectively applied across mental health and other settings, the utility of these models in aged care settings has not been assessed. The objective of this study was to examine whether TIC can reduce responsive behaviour, chemical restraint, and improve staff skills and patient experiences in inpatient geriatric settings. METHODS: Four wards participated in this type I hybrid implementation-effectiveness study across southern Adelaide, Australia, including 79 beds. Using a co-design method, the principles of TIC were transformed into an implementation strategy including staff training, establishment of highly trained 'champions' on each ward, screening for trauma-related needs, and amending ward policies and procedures. Primary outcomes will be examined using an interrupted time-series design and are monthly incidence of responsive behaviour incidents and use of chemical restraint. Process evaluation will be used to examine secondary, implementation outcomes including the acceptability, feasibility, and fidelity to the implementation strategy. DISCUSSION: Trauma-informed care has potential to improve the safety and accessibility of hospital wards for older people who have survived psychologically traumatic events and has an extensive evidence base supporting its effectiveness in other settings. Identifying trauma-related needs and amending care to reduce the risk of re-traumatisation and distress may also reduce the incidence of responsive behaviour change, which has a significant impact on the quality of life of hospital patients and staff and is very costly. The inclusion of a process evaluation will allow us to identify and report changes made on each ward and make recommendations for future implementation efforts.

Variation in psychosocial influences according to the dimensions and content of children's unusual experiences: potential routes for the development of targeted interventions.

The psychosocial processes implicated in the development and maintenance of psychosis differ according to both the dimensional attributes (conviction, frequency, associated distress, adverse life impact) and the content or type (e.g. grandiosity, hallucinations, paranoia) of the psychotic symptoms experienced. This has informed the development of 'targeted' cognitive behavioural therapy for psychosis (CBTp): interventions focusing on specific psychological processes in the context of particular symptom presentations. In adults, larger effect sizes for change in primary outcomes are typically reported in trials of targeted interventions, compared to those for trials of generic CBTp approaches with multiple therapeutic foci. We set out to test the theoretical basis for developing targeted CBTp interventions for young people with distressing psychotic-like, or unusual, experiences (UEs). We investigated variations in the psychosocial processes previously associated with self-reported UE severity (reasoning, negative life events, emotional problems) according to UE dimensional attributes and content/type (using an established five-factor model) in a clinically referred sample of 72 young people aged 8-14 years. Regression analyses revealed associations of conviction and grandiosity with reasoning; of frequency, and hallucinations and paranoia, with negative life events; and of distress/adverse life impact, and paranoia and hallucinations, with emotional problems. We conclude that psychological targets for intervention differ according to particular characteristics of childhood UEs in much the same way as for psychotic symptoms in adults. The development of targeted interventions is therefore indicated, and tailoring therapy according to presentation should further improve clinical outcomes for these young people.

Exploring the cognitive features in children with autism spectrum disorder, their co-twins, and typically developing children within a population-based sample.

BACKGROUND: The behavioural symptoms of autism spectrum disorder (ASD) are thought to reflect underlying cognitive deficits/differences. The findings in the literature are somewhat mixed regarding the cognitive features of ASD. This study attempted to address this issue by investigating a range of cognitive deficits and the prevalence of multiple cognitive atypicalities in a large population-based sample comprising children with ASD, their unaffected co-twins, and typically developing comparison children. METHODS: Participants included families from the Twins Early Development Study (TEDS) where one or both children met diagnostic criteria for ASD. Overall, 181 adolescents with a diagnosis of ASD and 73 unaffected co-twins were included, plus an additional 160 comparison control participants. An extensive cognitive battery was administered to measure IQ, central coherence, executive function, and theory of mind ability. RESULTS: Differences between groups (ASD, co-twin, control) are reported on tasks assessing theory of mind, executive function, and central coherence. The ASD group performed atypically in significantly more cognitive tasks than the unaffected co-twin and control groups. Nearly a third of the ASD group presented with multiple cognitive atypicalities. CONCLUSIONS: Multiple cognitive atypicalities appear to be a characteristic, but not universal feature, of ASD. Further work is needed to investigate whether specific cognitive atypicalities, either alone or together, are related to specific behaviours characteristic of ASD.

Cognitive bias and unusual experiences in childhood.

Cognitive therapy is recommended for children with psychotic-like, or unusual, experiences associated with distress or impairment (UEDs; UK National Institute for Health and Care Excellence, 2013 [1]). Accurate models of the psychological underpinnings of childhood UEDs are required to effectively target therapies. Cognitive biases, such as the jumping to conclusions data-gathering bias (JTC), are implicated in the development and maintenance of psychosis in adults. In this study, we aimed to establish the suitability for children of a task developed to assess JTC in adults. Eighty-six participants (aged 5-14 years) were recruited from Child and Adolescent Mental Health Service (CAMHS) and community (school) settings, and completed the probabilistic reasoning ('Beads') task, alongside measures of intellectual functioning, general psychopathology, and UEDs. Self-reported reasoning strategy was coded as 'probabilistic' or 'other'. Younger children (5-10 years) were more likely than older children (11-14 years) to JTC (OR = 2.7, 95 % CI = 1.1-6.5, p = 0.03); and to use non-probabilistic reasoning strategies (OR = 9.4, 95 % CI = 1.7-48.8, p = 0.008). Both UED presence (OR = 5.1, 95 % CI = 1.2-21.9, p = 0.03) and lower IQ (OR = 0.9, 95 % CI = 0.9-1.0, p = 0.02) were significantly and independently associated with JTC, irrespective of age and task comprehension. Findings replicate research in adults, indicating that the 'Beads' task can be reliably employed in children to assess cognitive biases. Psychological treatments for children with distressing unusual experiences might usefully incorporate reasoning interventions.

Modelling psychosocial influences on the distress and impairment caused by psychotic-like experiences in children and adolescents.

Psychological understanding of psychotic-like experiences (PLEs) occurring in childhood is limited, with no recognised conceptual framework to guide appropriate intervention. We examined the contribution to PLE severity of emotional, cognitive and socio-environmental mechanisms thought to influence the development and maintenance of psychosis. Forty 8-14 year olds referred to a community Child and Adolescent Mental Health Service completed a battery of questionnaires and assessments measuring severity of PLEs, emotional problems, cognitive biases, and negative life events. 85% of children assessed reported having experienced a PLE over the previous year; and 55% reported more than one. 60% had experienced at least one in the previous fortnight. Multiple linear regression demonstrated that each of the variables made a significant and independent contribution to PLE severity, after adjusting for verbal ability and age, accounting together for more than half of the variance (reasoning B = 6.324, p = .049; emotion B = 1.807, p = .005; life events B = 4.039, p = .001). PLEs were common in this clinical sample of children. Psychological factors implicated in the development and maintenance of psychosis in adults were also associated with PLE severity in these children. PLE severity may be reduced by targeting each of these factors in cognitive therapy, at this very early stage. Any improvements in emotional wellbeing and functioning may then increase future resilience.

Mindfulness-based cognitive therapy for depression in adolescents.

BACKGROUND: Mindfulness-Based Cognitive Therapy (MBCT) has been shown to be effective in preventing relapse of depression in adults, but has not previously been applied to adolescents who have residual symptoms of depression following treatment. METHOD: An 8-week MBCT group was adapted for adolescents, and evaluated using qualitative and quantitative measures. RESULTS: Participants report high levels of satisfaction with the group intervention. Qualitative analysis of semi-structured interviews provides areas for future development of this intervention. Pilot data indicate reductions in depressive symptoms, alongside positive change in mindfulness skills, quality of life and rumination. CONCLUSIONS: Preliminary evidence for the use of MBCT with this group of adolescents is provided.

Exploring anxiety symptoms in a large-scale twin study of children with autism spectrum disorders, their co-twins and controls.

BACKGROUND: Although many children with autism spectrum disorders (ASDs) experience difficulties with anxiety,the manifestation of these difficulties remains unresolved. The current study assessed anxiety in a large population based twin sample, aged 10­15 years. Phenotypic analyses were used to explore anxiety symptoms in children with ASDs, their unaffected co-twins and a control sample. METHODS: Participants included 146 families from the Twins Early Development Study (TEDS) where one or both children had a suspected ASD. Eighty control families were also included. The Revised Child Anxiety and Depression scale (Chorpita, Yim, Moffitt, Umemoto & Francis, 2000) was completed (self- and parent-report), along with diagnostic and cognitive tests. Children were categorized into four groups (a) ASD (b) Broader Autism Phenotype (BAP: mainly co-twins of children with ASDs, with high subclinical autistic traits) (c) unaffected co-twins (with neither ASDs nor BAP) (d) controls. RESULTS: Children in the ASD and BAP groups scored significantly higher than controls for all parent-rated (although not child-rated) anxiety subscales.There were no significant differences between the ASD and BAP groups for any of the parent-rated anxiety subscales. Compared with controls, unaffected co-twins showed significantly heightened Social Anxiety, Generalized Anxiety,and Panic symptoms. Significant associations were observed between certain anxiety subscales and both IQ and ASD symptoms. For example, greater parent-rated Social Anxiety was associated with higher IQ and increased social and communicative impairments. Significant interrater correlations were observed for anxiety reports in children with ASDs (r = .27­.54; p < .01), their unaffected co-twins (r = .32­.63; p < .01) and controls (r = .23­.43; p < .01)suggesting that children in this sample with and without ASD symptoms were able to report on their anxiety symptoms with some accuracy. CONCLUSIONS: These findings support previous reports of heightened anxiety in children with ASDs, at least on parent-reported measures. Unaffected co-twins of children with ASDs also showed increased anxiety, generating questions about the potential etiological overlap between ASDs and anxiety. Progress in this area now depends on more refined anxiety measurement in ASDs and continued investigation of interrater differences.

Psychiatric conditions and behavioural problems in adolescents with intellectual disabilities: correlates with autism.

OBJECTIVE: To determine whether psychiatric and behavioural disorders occur more frequently in adolescents with autism and intellectual disabilities, compared with those without autism. METHOD: A population-based case-control study was undertaken and 36 adolescents with autism were pairwise matched for age and IQ to 36 adolescents without autism. Caregivers were interviewed with structured psychiatric interview and questionnaire measures of psychiatric and behavioural problems. RESULTS: Compulsive behaviours and stereotypies were significantly more common in adolescents with autism. CONCLUSIONS: Adolescents with autism are prone to compulsive behaviours and stereotypies as well as specific manifestations of anxiety, fears, and phobias.

The problem with using eye-gaze to infer desire: a deficit of cue inference in children with autism spectrum disorder?

Children with autism respond atypically to eye-gaze cues, arguably because they fail to understand that eye-gaze conveys mentalistic information. Three experiments investigated whether a difficulty in inferring desire from eye-gaze in autism reflects a failure to understand the mentalistic significance of eye-gaze, an inhibitory deficit or a deficit of cue inference. While there was an inhibitory component to the tasks, children with autism were no more affected by this than controls. In addition, individuals' impairment in inferring desire was not limited to social cues, but was also observed when desire was cued by more general cues. Consequently, children with autism may have a general deficit in using arbitrary cues to make inferences, which impacts particularly on their social development.

Are ADHD traits dissociable from the autistic profile? Links between cognition and behaviour.

Reports of co-morbid symptoms of ADHD in children with ASD have increased. This research sought to identify ADHD-related behaviours in a sample of children with ASD, and their relationship with the ASD triad of impairments and related cognitive impairments. Children with ASD (n = 55) completed a comprehensive cognitive assessment whilst a semi-structured parental interview (3Di) provided information on ASD and ADHD symptoms. Co-morbid presentation of ADHD traits in these participants was associated with reports of more ASD related behaviours. Inhibitory control performance was directly related only to the ADHD symptom of impulsive behaviour. In contrast, while there was a relationship between social difficulties associated with ASD and theory of mind ability, there was no such relationship with behaviours relating to ADHD.

Identifying symbolic relationships in autism spectrum disorders: a deficit in the identification of temporal co-occurrence?

Individuals with Autism spectrum disorders (ASD) experience difficulties understanding the non-verbal cues conveyed by others that provide symbolic information about relationships between self, other, and environmental events. This study examined whether these difficulties reflect underlying problems in the identification of temporal co-occurrence, or in memorial, associative, or inference skills. The performance of a group of adolescents with ASD was compared to that of typically developing children and adolescents with learning difficulties on four tasks assessing these processes. The ASD group experienced specific difficulties when they were required to identify relationships signalled by the temporal co-occurrence of stimuli. These results are discussed in relation to theories of conceptual deduction in ASD, and a hypothesised role in social cognitive development for attention processes is outlined.