A church-based intervention for families to promote mental health and prevent HIV among adolescents in rural Kenya: Results of a randomized trial.

OBJECTIVE: To evaluate a family- and church-based intervention for adolescents and caregivers in rural Kenya to improve family relationships, reduce HIV risk, and promote mental health. METHOD: The intervention was developed using community-based participatory methods and focused on strengthening family communication. Modules addressed economic, relationship, and HIV-related topics using evidence-based behavioral strategies alongside culturally grounded content. A stepped wedge cluster randomized trial was conducted with 124 families (237 adolescents ages 10 to 16; 203 caregivers) from 4 churches. Participants completed interviewer-administered surveys over 5 rounds. Primary outcomes included family communication, HIV risk knowledge, self-efficacy, and beliefs. Secondary outcomes included parenting, social support, mental health, and adolescent sexual behavior. We estimated intent-to-treat effects via ordinary least squares regression with clustered standard errors. RESULTS: Relative to controls, the intervention group reported better family communication across domains at 1- and 3-months postintervention and higher self-efficacy for risk reduction skills and HIV-related knowledge at 1-month postintervention. Sexually active youth in the intervention reported fewer high-risk behaviors at 1-month postintervention, including unprotected sex or multiple partners. Male caregivers in the intervention reported higher parental involvement at both time points, and youth reported more social support from male caregivers at 3-months postintervention. No effects on secondary outcomes of parenting, social support, and mental health were detected. CONCLUSIONS: This intervention holds promise for strengthening positive family processes to protect against negative future outcomes for adolescents. Implementation with religious congregations may be a promising strategy for improving sustainability and scalability of interventions in low-resource settings. (PsycINFO Database Record

Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries.

BACKGROUND: Many people with mental, neurological and substance-use disorders (MNS) do not receive health care. Non-specialist health workers (NSHWs) and other professionals with health roles (OPHRs) are a key strategy for closing the treatment gap. OBJECTIVES: To assess the effect of NSHWs and OPHRs delivering MNS interventions in primary and community health care in low- and middle-income countries. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 21 June 2012); MEDLINE, OvidSP; MEDLINE In Process & Other Non-Indexed Citations, OvidSP; EMBASE, OvidSP (searched 15 June 2012); CINAHL, EBSCOhost; PsycINFO, OvidSP (searched 18 and 19 June 2012); World Health Organization (WHO) Global Health Library (searched 29 June 2012); LILACS; the International Clinical Trials Registry Platform (WHO); OpenGrey; the metaRegister of Controlled Trials (searched 8 and 9 August 2012); Science Citation Index and Social Sciences Citation Index (ISI Web of Knowledge) (searched 2 October 2012) and reference lists, without language or date restrictions. We contacted authors for additional studies. SELECTION CRITERIA: Randomised and non-randomised controlled trials, controlled before-and-after studies and interrupted-time-series studies of NSHWs/OPHR-delivered interventions in primary/community health care in low- and middle-income countries, and intended to improve outcomes in people with MNS disorders and in their carers. We defined an NSHW as any professional health worker (e.g. doctors, nurses and social workers) or lay health worker without specialised training in MNS disorders. OPHRs included people outside the health sector (only teachers in this review). DATA COLLECTION AND ANALYSIS: Review authors double screened, double data-extracted and assessed risk of bias using standard formats. We grouped studies with similar interventions together. Where feasible, we combined data to obtain an overall estimate of effect. MAIN RESULTS: The 38 included studies were from seven low- and 15 middle-income countries. Twenty-two studies used lay health workers, and most addressed depression or post-traumatic stress disorder (PTSD). The review shows that the use of NSHWs, compared with usual healthcare services: 1. may increase the number of adults who recover from depression or anxiety, or both, two to six months after treatment (prevalence of depression: risk ratio (RR) 0.30, 95% confidence interval (CI) 0.14 to 0.64; low-quality evidence); 2. may slightly reduce symptoms for mothers with perinatal depression (severity of depressive symptoms: standardised mean difference (SMD) -0.42, 95% CI -0.58 to -0.26; low-quality evidence); 3. may slightly reduce the symptoms of adults with PTSD (severity of PTSD symptoms: SMD -0.36, 95% CI -0.67 to -0.05; low-quality evidence); 4. probably slightly improves the symptoms of people with dementia (severity of behavioural symptoms: SMD -0.26, 95% CI -0.60 to 0.08; moderate-quality evidence); 5. probably improves/slightly improves the mental well-being, burden and distress of carers of people with dementia (carer burden: SMD -0.50, 95% CI -0.84 to -0.15; moderate-quality evidence); 6. may decrease the amount of alcohol consumed by people with alcohol-use disorders (drinks/drinking day in last 7 to 30 days: mean difference -1.68, 95% CI -2.79 to -0.57); low-quality evidence).It is uncertain whether lay health workers or teachers reduce PTSD symptoms among children. There were insufficient data to draw conclusions about the cost-effectiveness of using NSHWs or teachers, or about their impact on people with other MNS conditions. In addition, very few studies measured adverse effects of NSHW-led care - such effects could impact on the appropriateness and quality of care. AUTHORS' CONCLUSIONS: Overall, NSHWs and teachers have some promising benefits in improving people's outcomes for general and perinatal depression, PTSD and alcohol-use disorders, and patient- and carer-outcomes for dementia. However, this evidence is mostly low or very low quality, and for some issues no evidence is available. Therefore, we cannot make conclusions about which specific NSHW-led interventions are more effective.

Developing a family-based HIV prevention intervention in rural Kenya: challenges in conducting community-based participatory research.

Community-Based Participatory research (CBPR) introduces new ethical challenges for HIV prevention studies in low-resource international settings. We describe a CBPR study in rural Kenya to develop and pilot a family-based HIV prevention and mental health promotion intervention. Academic partners (APs) worked with a community advisory committee (CAC) during formative research, intervention development, and a pilot trial. Ethical challenges emerged related to: negotiating power imbalances between APs and the CAC; CAC members' shifting roles as part of the CAC and wider community; and anticipated challenges in decision making about sustainability. Factors contributing to ethical dilemmas included low access to education, scarcity of financial resources, and the shortage of HIV-related services despite high prevalence.

The relation between maternal ADHD symptoms & improvement in child behavior following brief behavioral parent training is mediated by change in negative parenting.

This study examined the extent to which maternal attention-deficit/hyperactivity disorder (ADHD) symptoms predict improvement in child behavior following brief behavioral parent training. Change in parenting was examined as a potential mediator of the negative relationship between maternal ADHD symptoms and improvement in child behavior. Seventy mothers of 6-10 year old children with ADHD underwent a comprehensive assessment of adult ADHD prior to participating in an abbreviated parent training program. Before and after treatment, parenting was assessed via maternal reports and observations and child disruptive behavior was measured via maternal report. Controlling for pre-treatment levels, maternal ADHD symptomatology predicted post-treatment child disruptive behavior problems. The relation between maternal ADHD symptomatology and improvement in child behavior was mediated by change in observed maternal negative parenting. This study replicated findings linking maternal ADHD symptoms with attenuated child improvement following parent training, and is the first to demonstrate that negative parenting at least partially explains this relationship. Innovative approaches combining evidence-based treatment for adult ADHD with parent training may therefore be necessary for families in which both the mother and child have ADHD. Larger-scale studies using a full evidence-based parent training program are needed to replicate these findings.

Effects of maternal stimulant medication on observed parenting in mother-child dyads with attention-deficit/hyperactivity disorder.

This pilot study of 23 mothers with attention-deficit/hyperactivity disorder (ADHD) and their offspring with ADHD examined the effects of maternal stimulant medication on observed interactions. Parent-child interactions were observed using a structured protocol before and after mothers underwent a 5-week, double-blind stimulant titration. Despite dramatic effects of medication on adult ADHD symptoms, this small pilot and open label laboratory-based study did not identify maternal stimulant effects on observed parenting or child behavior. Given the documented impairments in parenting displayed by adults with ADHD, behavioral parenting interventions may be needed in conjunction with medication for mothers with ADHD to optimize family outcomes.

Associations between maternal attention-deficit/hyperactivity disorder symptoms and parenting.

Mothers of children with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for an ADHD diagnosis themselves, which is likely associated with impairments in parenting. The present study utilized a multi-method assessment of maternal ADHD and parenting to examine the extent to which maternal ADHD symptoms are associated with maladaptive parenting. Participants included 70 6-10 year old children with DSM-IV ADHD and their biological mothers. Results suggested that mothers with higher levels of ADHD symptoms reported lower levels of involvement and positive parenting and higher levels of inconsistent discipline. During observed parent-child interactions, maternal ADHD symptoms were negatively associated with positive parenting, and positively associated with negative parenting and repeated commands before giving the child an opportunity to comply. Given prior research suggesting that maladaptive parenting behaviors are risk factors for the later development of conduct problems among children with ADHD, these findings have important clinical implications for family-based assessment and treatment of ADHD.

Efficacy of osmotic-release oral system (OROS) methylphenidate for mothers with attention-deficit/hyperactivity disorder (ADHD): preliminary report of effects on ADHD symptoms and parenting.

OBJECTIVE: A preliminary study to examine the efficacy of osmotic-release oral system (OROS) methylphenidate for attention-deficit/hyperactivity disorder (ADHD) symptoms and parenting behaviors in mothers with ADHD who had children with ADHD. METHOD: Participants included 23 mother-child dyads in which both were diagnosed with DSM-IV ADHD. Mothers underwent a 5-week, double-blind titration (placebo, 36 mg/day, 54 mg/day, 72 mg/day, 90 mg/day) to an optimal dose of OROS methylphenidate, followed by random assignment to 2 weeks of placebo or their maximally effective dose. Primary outcome measures included maternal ADHD symptoms (Conners' Adult ADHD Rating Scale) and parenting (Alabama Parenting Questionnaire). Secondary outcomes included side effects ratings. Data were collected from December 2004 until August 2006. RESULTS: During Phase 1, mothers reported significant decreases in inattention (p < .001) and hyperactivity/impulsivity (p < .01) with increases in OROS methylphenidate dose. As dose increased, significant reductions in inconsistent discipline (p < .01) and corporal punishment use (p < .005) were also demonstrated. During Phase 2, small effects on inattention (d = 0.46) and hyperactivity/impulsivity (d = 0.38) were found for those randomly assigned to medication versus placebo. In addition, medium to large medication effects were found on maternal involvement (d = 0.52), poor monitoring/supervision (d = 0.70), and inconsistent discipline (d = 0.71), with small effects on corporal punishment (d = 0.42). During both phases, few adverse effects were noted. CONCLUSIONS: OROS methylphenidate was well tolerated and was associated with significant improvement in maternal ADHD symptoms and parenting. Variable effects on parenting suggest that behavioral interventions may be necessary to address impairments in parenting among adults with ADHD. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00318981.