A longitudinal comparison of emotional, behavioral and attention problems in autistic and typically developing children.

BACKGROUND: Mental health problems are elevated in autistic individuals but there is limited evidence on the developmental course of problems across childhood. We compare the level and growth of anxious-depressed, behavioral and attention problems in an autistic and typically developing (TD) cohort. METHODS: Latent growth curve models were applied to repeated parent-report Child Behavior Checklist data from age 2-10 years in an inception cohort of autistic children (Pathways, N = 397; 84% boys) and a general population TD cohort (Wirral Child Health and Development Study; WCHADS; N = 884, 49% boys). Percentile plots were generated to quantify the differences between autistic and TD children. RESULTS: Autistic children showed elevated levels of mental health problems, but this was substantially reduced by accounting for IQ and sex differences between the autistic and TD samples. There was small differences in growth patterns; anxious-depressed problems were particularly elevated at preschool and attention problems at late childhood. Higher family income predicted lower base-level on all three dimensions, but steeper increase of anxious-depressed problems. Higher IQ predicted lower level of attention problems and faster decline over childhood. Female sex predicted higher level of anxious-depressed and faster decline in behavioral problems. Social-affect autism symptom severity predicted elevated level of attention problems. Autistic girls' problems were particularly elevated relative to their same-sex non-autistic peers. CONCLUSIONS: Autistic children, and especially girls, show elevated mental health problems compared to TD children and there are some differences in predictors. Assessment of mental health should be integrated into clinical practice for autistic children.

The Family-Check-Up® Autism Implementation Research (FAIR) Study: protocol for a study evaluating the effectiveness and implementation of a family-centered intervention within a Canadian autism service setting.

Introduction: Prevalence rates of emotional and behavior problems (EBP) in autistic children and youth are high (40-70%), and often cause severe and chronic impairment. Furthermore, autistic children are also more likely to experience family "social-ecological" adversity compared to neurotypically developing peers, including social isolation, child maltreatment, caregiver mental illness, and socioeconomic risk. These family stressors increase the risk of co-occurring EBP among autistic children and can often impede access to evidence-based care, thus amplifying long-term health inequities for autistic children and their caregivers. In the current autism services landscape, there are few scalable, evidence-based programs that adequately address these needs. The Family Check-Up (FCU®) is a brief, strength-based, and tailored family-centered intervention that supports positive parenting and explicitly assesses the social determinants of child and family mental health within an ecological framework. Studies have demonstrated long-term positive child and caregiver outcomes in other populations, but the FCU® has not been evaluated in families of autistic children and youth. Therefore, we aimed to evaluate FCU® implementation within an established, publicly funded Autism Program in Ontario, Canada, with delivery by autism therapists, to demonstrate sustainable effectiveness within real-world settings. Methods: In this study, we outline the protocol for a hybrid implementation-effectiveness approach with two key components: (1) A parallel-arm randomized controlled trial of N = 80 autistic children/youth (ages 6-17 years) and high levels of EBP and their caregivers. Primary and secondary outcomes include child EBP, and caregiver well-being and parenting. (2) A mixed methods implementation study, to describe facilitators and barriers to implementation of the FCU® within an autism service setting. Discussion: Scalable, ecologically focused family-centered interventions offer promise as key components of a public health framework aimed at reducing mental health inequities among autistic children, youth, and their caregivers. Results of this study will inform further program refinement and scale-up.

Non-verbal IQ and change in restricted and repetitive behavior throughout childhood in autism: a longitudinal study using the Autism Diagnostic Interview-Revised.

BACKGROUND: Restricted and repetitive behavior (RRB) is one of the characteristic features of Autism Spectrum Disorder. This domain of symptoms includes a broad range of behaviors. There is a need to study each behavior individually to better understand the role of each in the development of autistic children. Moreover, there are currently no longitudinal studies investigating change in these behaviors over development. METHODS: The goal of the present study was to explore the association between age and non-verbal IQ (NVIQ) on 15 RRB symptoms included in the Autism Diagnostic Interview-Revised (ADI-R) over time. A total of 205 children with ASD were assessed using the ADI-R at time of diagnosis, at age 6 years, and at age 11 years, and with the Wechsler Intelligence Scales for Children-Fourth Edition (WISC-IV) at age 8 years. RESULTS: The proportion of children showing each RRB tended to diminish with increasing age, except for sensitivity to noise and circumscribed interests, where the proportion increased over time. Although there was no significant main effect of NVIQ, there was a significant interaction between age and NVIQ. This was mainly driven by Difficulties with change in routine, for which higher NVIQ was associated with the behavior remaining relatively stable with age, while lower NVIQ was associated with the behavior becoming more prevalent with age. LIMITATIONS: The study focused on the presence/absence of each RRB but did not account for potential changes in frequency or severity of the behaviors over development. Furthermore, some limitations are inherent to the measures used. The ADI-R relies on parent report and hence has some level of subjectivity, while the Wechsler intelligence scales can underestimate the intellectual abilities of some autistic children. CONCLUSIONS: These results confirm that specific RRB are differentially linked to age and NVIQ. Studying RRB individually is a promising approach to better understanding how RRB change over the development of autistic children and are linked to other developmental domains.

Immigrant and ethnic neighbourhood concentration and reduced child developmental vulnerability: A Canadian cohort study.

INTRODUCTION: Studies have consistently demonstrated a gradient between median neighbourhood income and child developmental outcomes. By investigating statistical outliers-neighbourhoods with children exhibiting less or more developmental vulnerability than that predicted by median neighbourhood income-there is an opportunity to identify other neighbourhood characteristics that may be enhancing or impeding early childhood development. OBJECTIVE: Testing a variety of neighbourhood factors, including immigrant or ethnic concentration and characteristics of structural disadvantage (proportion of social assistance recipients, homes in need of major repair, residents with high school education only, lone parent families, and residents moving in the last year) we sought to identify factors associated with more or less developmental vulnerability than that predicted by median neighbourhood income, for young children. METHODS: For this cross-sectional study we used validated Early Development Instrument (EDI) data (2003-2013) linked to demographic and socioeconomic Census and Tax Filer data for 98.3% of Canadian neighbourhoods (n=2,023). The purpose of the instrument is to report, at a population-level, children's school readiness. Children's developmental vulnerability was assessed in five domains (physical health and well-being, emotional maturity, social competence, language and cognitive development, and communication and general knowledge) in relation to the 10th percentile from a national normative sample. Levels of children's neighbourhood vulnerability were determined per domain, as percent of children vulnerable at a given domain. Neighbourhoods were grouped into three cohorts, those having lower than predicted, as predicted, or higher than predicted children's vulnerability according to neighbourhood median income. Using multivariable binary logistic regression we modelled the association between select neighbourhood characteristics and neighbourhoods with lower or higher than predicted vulnerability per domain, compared to neighbourhoods with predicted vulnerability. This allowed us to determine neighbourhood characteristics associated with better or worse child developmental outcomes, at a neighbourhood-level, than that predicted by income. RESULTS: In neighbourhoods with less child developmental vulnerability than that predicted by income, high or low immigrant concentration and ethnic homogeneity was associated with less vulnerability in physical (adjusted odds ratio (aOR) 1.66, 95% CI: 1.43, 1.94), social (aOR 1.30, 95% CI: 1.11, 1.51), and communication domains (aOR 1.24, 95% CI: 1.03, 1.47) compared to neighbourhoods with vulnerability concordant with income. Neighbourhood ethnic homogeneity was consistently associated with less developmental vulnerability than predicted by income across all developmental domains. Neighbourhood-level structural disadvantage was strongly associated with child developmental vulnerability beyond that predicted by median neighbourhood income. CONCLUSION: Canadian neighbourhoods demonstrating less child developmental vulnerability than that predicted by income have greater ethnic and ethnic-immigrant homogeneity than neighbourhoods with child developmental vulnerability concordant with income. Neighbourhood social cohesion and cultural identity may be contributing factors. Neighbourhood structural disadvantage is associated with poorer early childhood development, over and above that predicted by neighbourhood income. Neighbourhood-level policy and programming should address income and non-income related barriers to healthy child development.

Examining Trajectories of Daily Living Skills over the Preschool Years for Children with Autism Spectrum Disorder.

Preschool children with autism spectrum disorder (ASD) experience slower development of daily living skills (DLS) that are essential for independent functioning compared to typically developing children. Few studies have examined the trajectories of DLS in preschoolers with ASD and the existing literature has reported conflicting results. This study examined DLS trajectories and potential covariates for preschoolers with ASD from a multi-site longitudinal study following children from diagnosis to the end of grade 1. Multi-level modeling was conducted with DLS domain scores from the Vineland Adaptive Behavior Scales-2. The results demonstrated a positive trajectory of increasing scores over time, associations of age of diagnosis, developmental level, stereotypy, and language skills with the mean score at T4 or age 6 years, whereas rate of change was only associated with ASD symptom severity, such that an improvement in DLS trajectory was associated with lower and improving ASD symptom severity.

Eye Tracking Effort Expenditure and Autonomic Arousal to Social and Circumscribed Interest Stimuli in Autism Spectrum Disorder.

The social communicative deficits and repetitive behaviours seen in Autism Spectrum Disorder (ASD) may be affected by altered stimulus salience and reward attribution. The present study used eye tracking and a behavioural measure to index effort expenditure, arousal, and attention, during viewing of images depicting social scenes and subject-specific circumscribed interests in a group of 10 adults with ASD (mean age 25.4 years) and 19 typically-developing controls (mean age 20.7 years) Split-plot and one-way repeated measures ANOVAs were used to explore results. A significant difference between the ASD and control group was found in the amount of effort expended to view social and circumscribed images. The ASD group also displayed significant differences in pupillary response to social and circumscribed images, indicative of changes in autonomic arousal. Overall, the results support the social motivation hypothesis in ASD (Chevallier et al., Trends Cogn Sci 16(4):231-239, 2012) and suggest a role for autonomic arousal in the ASD symptom dyad.

Variability in Verbal and Nonverbal Communication in Infants at Risk for Autism Spectrum Disorder: Predictors and Outcomes.

Early communication impairment is among the most-reported first concerns in parents of young children with autism spectrum disorder (ASD). Using a parent-report questionnaire, we derived trajectory groups for early language and gesture acquisition in siblings at high risk for ASD and in children at low risk, during their first 2 years of life. Developmental skills at 6 months were associated with trajectory group membership representing growth in receptive language and gestures. Behavioral symptoms also predicted gesture development. All communication measures were strongly related to clinical and developmental outcomes. Trajectory groups further indicated slowest language/gesture acquisition in infants with later ASD diagnoses, in particular when associated with language delay. Overall, our results confirm considerable variability in communication development in high-risk infants.

Patterns of multiple health risk-behaviours in university students and their association with mental health: application of latent class analysis. / Profils de multiples comportements à risque pour la santé des étudiants universitaires et leurs liens avec la santé mentale : utilisation de l'analyse des classes latentes.

INTRODUCTION: University and college campuses may be the last setting where it is possible to comprehensively address the health of a large proportion of the young adult population. It is important that health promoters understand the collective challenges students are facing, and to better understand the broader lifestyle behavioural patterning evident during this life stage. The purpose of this study was to examine the clustering of modifiable health-risk behaviours and to explore the relationship between these identified clusters and mental health outcomes among a large Canadian university sample. METHODS: Undergraduate students (n = 837; mean age = 21 years) from the University of Toronto completed the National College Health Assessment survey. The survey consists of approximately 300 items, including assessments of student health status, mental health and health-risk behaviours. Latent class analysis was used to identify patterning based on eight salient health-risk behaviours (marijuana use, other illicit drug use, risky sex, smoking, binge drinking, poor diet, physical inactivity, and insufficient sleep). RESULTS: A three-class model based on student behavioural patterns emerged: "typical," "high-risk" and "moderately healthy." Results also found high-risk students reporting significantly higher levels of stress than typical students (χ2(1671) = 7.26, p < .01). CONCLUSION: Students with the highest likelihood of engaging in multiple health-risk behaviours reported poorer mental health, particularly as it relates to stress. Although these findings should be interpreted with caution due to the 28% response rate, they do suggest that interventions targeting specific student groups with similar patterning of multiple health-risk behaviours may be needed.

INTRODUCTION: Les campus universitaires et collégiaux sont sans doute les derniers milieux au sein desquels il est possible d'aborder de façon globale la question de la santé d'une grande proportion de la population de jeunes adultes. Il est important que les promoteurs de la santé saisissent en quoi consistent les difficultés collectives auxquelles font face les étudiants et qu'ils comprennent mieux les modèles plus larges de comportements liés au mode de vie qui se manifestent au cours de cette période de la vie. L'objectif de notre étude a été de déterminer des catégories de comportements à risque pour la santé modifiables et d'étudier la relation entre ces catégories et divers paramètres relevant de la santé mentale au sein d'un vaste échantillon d'étudiants universitaires canadiens. MÉTHODOLOGIE: Des étudiants de premier cycle (n = 837, âge moyen = 21 ans) de l'Université de Toronto ont répondu à l'enquête National College Health Assessment (NCHA) (évaluation nationale de la santé dans les collèges) qui comprend environ 300 éléments, dont des évaluations de l'état de santé, de la santé mentale et des comportements à risque pour la santé des étudiants. Nous avons réalisé une analyse des classes latentes pour relever des profils en fonction de huit comportements à risque pour la santé connus (consommation de marijuana, consommation d'autres drogues illégales, rapports sexuels à risque, tabagisme, excès occasionnel d'alcool, mauvaise alimentation, inactivité physique, manque de sommeil). RÉSULTATS: Nous avons obtenu un modèle à trois catégories axé sur les profils de comportement des étudiants : étudiants « typiques ¼, « à risque élevé ¼ et « relativement en bonne santé ¼. Nos résultats ont par ailleurs montré que les étudiants à risque élevé ont déclaré souffrir d'un niveau de stress considérablement plus élevé que celui des étudiants typiques (χ2 [1671] = 7,26; p < 0,01). CONCLUSION: Les étudiants les plus susceptibles d'adopter de multiples comportements à risque pour la santé ont fait état d'une moins bonne santé mentale, particulièrement en ce qui concerne le stress. Bien que l'on doive interpréter ces conclusions avec prudence en raison du taux de réponse de 28 %, celles-ci suggèrent néanmoins que l'on pourrait envisager des interventions ciblées auprès de groupes d'étudiants ayant des profils similaires de multiples comportements à risque pour la santé.

Health care and social service professionals' perceptions of a home-visit program for young, first-time mothers.

INTRODUCTION: Little is known about health care and social service professionals' perspective on the acceptability of long-term home-visit programs serving low-income, first-time mothers. This study describes the experiences and perspectives of these community care providers involved with program referrals or service delivery to mothers who participated in the Nurse-Family Partnership (NFP), a targeted nurse home-visit program. METHODS: The study included two phases. Phase I was a secondary qualitative data analysis used to analyze a purposeful sample of 24 individual interviews of community care providers. This was part of a larger case study examining adaptations required to increase acceptability of the NFP in Hamilton, Ontario, Canada. In Phase II (n = 4), themes identified from Phase I were further explored through individual, semi-structured interviews with community health care and social service providers, giving qualitative description. RESULTS: Overall, the NFP was viewed as addressing an important service gap for first-time mothers. Providers suggested that frequent communication between the NFP and community agencies serving these mothers could help improve the referral process, avoid service duplication, and streamline the flow of service access. The findings can help determine key components required to enhance the success of integrating a home-visit program into an existing network of community services. CONCLUSION: The function of home-visit programs should not be viewed in isolation. Rather, their potential can be maximized when they collaborate and share information with other agencies to provide better services for first-time mothers.

TITRE: Points de vue de professionnels de la santé et des services sociaux sur un programme de visites à domicile destiné aux jeunes mères d'un premier enfant. INTRODUCTION: On sait peu de choses sur ce que pensent les professionnels de la santé et des services sociaux des programmes à long terme de visites à domicile pour les nouvelles mères à faible revenu. Cette étude fait état des expériences et des points de vue de fournisseurs de services communautaires qui orientent les mères participant au Nurse-Family Partnership (NFP) ­ un programme de visites à domicile par une infirmière auprès de cette population cible ­ vers le programme lui-même ou qui interviennent directement dans le cadre de celui-ci. MÉTHODOLOGIE: L'étude s'est déroulée en deux phases. La phase I a consisté en une analyse secondaire de données qualitatives issues d'un échantillon de 24 entrevues individuelles dirigées avec des fournisseurs de soins communautaires, cette démarche s'inscrivant dans le cadre d'une étude de cas plus vaste réalisée à Hamilton (Ontario, Canada) et destinée à examiner les moyens à mettre en oeuvre pour accroître la recevabilité du NFP. La phase II, à laquelle ont pris part 4 participants, a consisté en une description qualitative des 3 thèmes relevés lors de la phase I, thèmes qui ont été approfondis au moyen d'entrevues individuelles semi-structurées menées auprès de certains fournisseurs de soins de santé et de services sociaux communautaires. RÉSULTATS: Le NFP est perçu dans l'ensemble comme un programme comblant une lacune importante dans les services dispensés aux nouvelles mères. Des échanges fréquents entre le NFP et les organismes communautaires offrant déjà des services à ces mères pourraient contribuer à en améliorer le processus d'orientation, à éviter leur chevauchement et à en faciliter l'accès. Ces résultats contribuent à mieux définir les composantes nécessaires au succès de l'intégration d'un programme de visites à domicile au réseau déjà en place de services communautaires. CONCLUSION: Le rôle des programmes de visites à domicile ne doit pas être envisagé isolément. Au contraire, le potentiel de ceux-ci est optimisé par la collaboration et l'échange d'information avec d'autres organismes afin d'offrir de meilleurs services aux mères d'un premier enfant.

Service utilization in a sample of preschool children with autism spectrum disorder: A Canadian snapshot.

OBJECTIVE: To describe services received by preschool children diagnosed with autism spectrum disorder (ASD) during the five-year period following their diagnosis. METHOD: An inception cohort of preschoolers diagnosed with ASD from Halifax (Nova Scotia), Montreal (Quebec), Hamilton (Ontario), Edmonton (Alberta) and Vancouver (British Columbia) were invited to participate. Parents/caregivers (n=414) described the services provided to their children at four time points: baseline (T1; within four months of diagnosis; mean age three years); six months later (T2); 12 months later (T3); and at school entry (T4). Data were first coded into 11 service types and subsequently combined into four broader categories (no services, behavioural, developmental and general) for analysis. RESULTS: More than 80% of children at T1, and almost 95% at T4 received some type of service, with a significant number receiving >1 type of service at each assessment point. At T1, the most common service was developmental (eg, speech-language therapy). Subsequently, the most common services were a combination of behavioural and developmental (eg, intensive therapy based on applied behaviour analysis and speech-language therapy). Service provision varied across provinces and over time. DISCUSSION: Although most preschool children with ASD residing in urban centres were able to access specialized services shortly after diagnosis, marked variation in services across provinces remains a concern.

OBJECTIF: Décrire les services qu'ont reçus des enfants d'âge préscolaire ayant un trouble du spectre autistique (TSA) pendant la période de cinq ans suivant leur diagnostic. MÉTHODOLOGIE: Une cohorte initiale d'enfants d'âge préscolaire ayant un TSA diagnostiqué et qui provenaient de Halifax (Nouvelle-Écosse), de Montréal (Québec), de Hamilton (Ontario), d'Edmonton (Alberta) ou de Vancouver (Colombie-Britannique) a été invitée à participer à l'étude. Les parents et les tuteurs (n=414) ont décrit les services fournis à leur enfant à quatre moments : au début (T1; dans les quatre mois suivant le diagnostic, âge moyen de trois ans); six mois plus tard (T2); 12 mois plus tard (T3) et à l'entrée à l'école (T4). Les chercheurs ont d'abord codé les données en 11 types de services, pour ensuite les regrouper en quatre catégories plus vastes (absence de services, comportementaux, développementaux et généraux) en vue de leur analyse. RÉSULTATS: Plus de 80 % des enfants ont reçu certains services à T1, et près de 95 % à T4, et un nombre significatif a reçu plus d'un type de services à chaque évaluation. À T1, le service le plus courant était de type développemental (p. ex., orthophonie). Par la suite, les services les plus courants étaient un mélange de services comportementaux et développementaux (p. ex., thérapie intensive selon l'analyse de comportement appliquée et orthophonie). La prestation des services variait selon les provinces et au fil du temps. EXPOSÉ: Même si la plupart des enfants d'âge préscolaire ayant un TSA qui habitaient dans un centre urbain avaient accès à des services spécialisés peu après le diagnostic, les variations marquées des services entre les provinces demeurent préoccupantes.

Language impairment and early social competence in preschoolers with autism spectrum disorders: a comparison of DSM-5 profiles.

Children with autism spectrum disorder (ASD) and structural language impairment (LI) may be at risk of more adverse social-developmental outcomes. We examined trajectories of early social competence (using the Vineland-II) in 330 children aged 2-4 years recently diagnosed with ASD, and compared 3 subgroups classified by: language impairment (ASD/LI); intellectual disability (ASD/ID) and ASD without LI or ID (ASD/alone). Children with ASD/LI were significantly more socially impaired at baseline than the ASD/alone subgroup, and less impaired than those with ASD/ID. Growth in social competence was significantly slower for the ASD/ID group. Many preschool-aged children with ASD/LI at time of diagnosis resembled "late talkers" who appeared to catch up linguistically. Children with ASD/ID were more severely impaired and continued to lag further behind.

Predictors of outcome among high functioning children with autism and Asperger syndrome.

BACKGROUND: The objective of this paper is to assess the extent to which measures of cognitive abilities taken in an inception cohort of young high functioning children with autism and Asperger syndrome predict outcome roughly two and six years later. METHOD: Children who received a diagnosis of autism or Asperger syndrome (AS) and who had a nonverbal IQ score in the 'non-retarded' range were included in the inception cohort. Measures of language and nonverbal skills were taken when the children were 4-6 years of age and outcome assessments were completed when the children were 6-8 and 10-13 years of age. The three outcome measures consisted of scales of adaptive behaviours in socialisation and communication and a composite measure of autistic symptoms (abnormal language, abnormal body and object use, difficulties relating to others, sensory issues and social and self-help difficulties). RESULTS: The explanatory power of the predictor variables was greater for communication and social skills than for autistic symptoms. The power of prediction was stable over time but did differ by PDD subtype. In general, the association between language skills and outcome was stronger in the autism group than in the AS group. CONCLUSIONS: These results support the emphasis of early intervention programmes on language but more work needs to be done on understanding variables that influence outcome in social skills and autistic behaviours, particularly in those with AS.

Childhood abuse and lifetime psychopathology in a community sample.

OBJECTIVE: The authors assessed lifetime psychopathology in a general population sample and compared the rates of five psychiatric disorder categories between those who reported a childhood history of either physical or sexual abuse and those who did not. METHOD: A modified version of the Composite International Diagnostic Interview and a self-completed questionnaire on child abuse were administered to a probability sample (N=7,016) of Ontario residents 15 to 64 years of age. RESULTS: Those reporting a history of childhood physical abuse had significantly higher lifetime rates of anxiety disorders, alcohol abuse/dependence, and antisocial behavior and were more likely to have one or more disorders than were those without such a history. Women, but not men, with a history of physical abuse had significantly higher lifetime rates of major depression and illicit drug abuse/dependence than did women with no such history. A history of childhood sexual abuse was also associated with higher rates of all disorders considered in women. In men, the prevalence of disorders tended to be higher among those who reported exposure to sexual abuse, but only the associations with alcohol abuse/dependence and the category of one or more disorders reached statistical significance. The relationship between a childhood history of physical abuse and lifetime psychopathology varied significantly by gender for all categories except for anxiety disorders. Although not statistically significant, a similar relationship was seen between childhood history of sexual abuse and lifetime psychopathology. CONCLUSIONS: A history of abuse in childhood increases the likelihood of lifetime psychopathology; this association appears stronger for women than men.

Helping children adjust--a Tri-Ministry Study: II. Program effects.

This report describes program effects of the Tri-Ministry Study a school-based, longitudinal trial carried out over a 5-year period to assess the effectiveness of classwide social skills training (SS), partner reading (RE), and a combination of both (SS & RE) to reduce maladjustment among children in the primary division (up to grade 3) of Ontario schools. It also places these effects in the context of other school-based prevention studies and discusses them in view of important methodological and programmatic issues. The incremental effects attributable to the intervention programs were small and sporadic. There were statistically significant increases in prosocial behaviour observed in the playgrounds of intervention schools with no differentiation by program type. Furthermore, there was some evidence--a reduction in teacher and parent-rated externalising problems--that the combination of SS & RE and SS alone may have had modest beneficial effects. A review of nine other school-based studies, which evaluated universally delivered mental health prevention programs in general populations of students, revealed similar mixed results. There are both methodologic and programmatic issues implicated in the weak findings that have been reported to date. These issues need to be addressed to advance knowledge about the potential impact of mental-health prevention initiatives delivered universally through school-based programs. A companion paper gives the specific details on the programs, randomisation of schools, selection of subjects, measurements, and analysis.

Slapping and spanking in childhood and its association with lifetime prevalence of psychiatric disorders in a general population sample.

BACKGROUND: Little information is available in Canada about the prevalence of and outcomes associated with a history of slapping and spanking in childhood. The objectives of this study were to estimate the prevalence of a history of slapping or spanking in a general population sample and to assess the relation between such a history and the lifetime prevalence of psychiatric disorders. METHODS: In this general population survey, a probability sample of 9953 residents of Ontario aged 15 years and older who participated in the Ontario Health Supplement was used to examine the prevalence of a history of slapping and spanking. A subgroup of this sample (n = 4888), which comprised people aged 15 to 64 years who did not report a history of physical or sexual abuse during childhood, was used to assess the relation between a history of slapping or spanking and the lifetime prevalence of 4 categories of psychiatric disorder. The measures included a self-administered questionnaire with a question about frequency of slapping and spanking during childhood, as well as an interviewer-administered questionnaire to measure psychiatric disorder. RESULTS: The majority of respondents indicated that they had been slapped or spanked, or both, by an adult during childhood "sometimes" (33.4%) or "rarely" (40.9%); 5.5% reported that this occurred "often." The remainder (20.2%) reported "never" experiencing these behaviours. Among the respondents without a history of physical or sexual abuse during childhood, those who reported being slapped or spanked "often" or "sometimes" had significantly higher lifetime rates of anxiety disorders (adjusted odds ratio [OR] 1.43, 95% confidence interval [CI] 1.04-1.96), alcohol abuse or dependence (adjusted OR 2.02, 95% CI 1.27-3.21) and one or more externalizing problems (adjusted OR 2.08, 95% CI 1.36-3.16), compared with those who reported "never" being slapped or spanked. There was also an association between a history of slapping or spanking and major depression, but it was not statistically significant (adjusted OR 1.64, 95% CI 0.96-2.80). INTERPRETATION: There appears to be a linear association between the frequency of slapping and spanking during childhood and a lifetime prevalence of anxiety disorder, alcohol abuse or dependence and externalizing problems.

A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma.

BACKGROUND: Chiropractic spinal manipulation has been reported to be of benefit in nonmusculoskeletal conditions, including asthma. METHODS: We conducted a randomized, controlled trial of chiropractic spinal manipulation for children with mild or moderate asthma. After a three-week base-line evaluation period, 91 children who had continuing symptoms of asthma despite usual medical therapy were randomly assigned to receive either active or simulated chiropractic manipulation for four months. None had previously received chiropractic care. Each subject was treated by 1 of 11 participating chiropractors, selected by the family according to location. The primary outcome measure was the change from base line in the peak expiratory flow, measured in the morning, before the use of a bronchodilator, at two and four months. Except for the treating chiropractor and one investigator (who was not involved in assessing outcomes), all participants remained fully blinded to treatment assignment throughout the study. RESULTS: Eighty children (38 in the active-treatment group and 42 in the simulated-treatment group) had outcome data that could be evaluated. There were small increases (7 to 12 liters per minute) in peak expiratory flow in the morning and the evening in both treatment groups, with no significant differences between the groups in the degree of change from base line (morning peak expiratory flow, P=0.49 at two months and P=0.82 at four months). Symptoms of asthma and use of 3-agonists decreased and the quality of life increased in both groups, with no significant differences between the groups. There were no significant changes in spirometric measurements or airway responsiveness. CONCLUSIONS: In children with mild or moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit.

Risk of fatal pulmonary embolism in patients with treated venous thromboembolism.

CONTEXT: The most serious complication of deep vein thrombosis (DVT) or nonfatal pulmonary embolism (PE) is fatal PE. However, reliable estimates as to the risk of fatal PE in patients with treated DVT or PE are lacking. OBJECTIVE: To provide reliable estimates of the risk of fatal PE and the case-fatality rate of recurrent DVT or PE among patients presenting with symptomatic DVT or PE, during and following 3 months of anticoagulant therapy. DATA SOURCES: A MEDLINE literature search was performed to identify prospective studies in which patients with symptomatic DVT or PE were treated with 5 to 10 days of heparin and 3 months of oral anticoagulants. We searched the years 1966 to September 1997 using the search terms thrombophlebitis, diagnosis, drug therapy, and prognosis. Current Contents and bibliographies were also scanned. DATA EXTRACTION: Of 137 retrieved studies, 25 studies satisfied predetermined methodologic criteria and were included in the analysis. DATA SYNTHESIS: Among patients presenting with DVT, the rate of fatal PE during anticoagulant therapy was 0.4% (95% confidence interval [CI], 0.2%-0.6%); following anticoagulant therapy it was 0.3 per 100 patient-years (95% CI, 0.1-0.8). The case-fatality rate of recurrent DVT or PE during anticoagulant therapy was 8.8% (95% CI, 5.0%-14.1%); following anticoagulant therapy it was 5.1% (95% CI, 1.4%-12.5%). Among patients presenting with PE, the rate of fatal PE during anticoagulant therapy was 1.5% (95% CI, 0.9%-2.2%); following anticoagulant therapy it was 0 per 265 patient-years (95% CI, 0-3.6). The case-fatality rate of recurrent DVT or PE among patients presenting with PE was 26.4% (95% CI, 16.7%-38.1%). CONCLUSION: Among patients with symptomatic PE or DVT who are treated with anticoagulants for 3 months, fatal PE is rare during and following anticoagulant therapy. Patients presenting with PE are more likely to die of recurrent PE or DVT than are patients presenting with DVT.

A reevaluation of the risk for venous thromboembolism with the use of oral contraceptives and hormone replacement therapy.

BACKGROUND: There are many health benefits associated with the use or oral contraceptives (OCs) and hormone replacement therapy (HRT), but these agents are also associated with potential health risks. OBJECTIVE: To reevaluate the current practice of withholding OCs or HRT in women with previous venous thromboembolism (VTE) by critically reviewing the evidence that the use of OCs or HRT is associated with an increased risk for VTE. METHODS: A MEDLINE literature search was performed to identify studies investigating associations between OCs and VTE or HRT and VTE. Each study was rated according to methodologic quality (level 1, low potential for bias; level 2, moderate potential for bias; level 3, high potential for bias). Results were combined across studies of similar design to determine pooled risk ratios for VTE. The results from studies investigating third-generation OCs were reported separately. RESULTS: For OC studies (n = 22), the pooled risk ratios (95% confidence intervals) in case-control studies, retrospective cohort studies, prospective cohort studies, and randomized controlled trials were 3.0 (2.6-3.4), 4.8 (2.5-7.7), 2.4 (1.6-3.5), and 1.1 (0.4-2.9), respectively. In users of third-generation OCs, the pooled risk ratio (95% confidence interval) for VTE was 5.0 (2.5-7.5). No study was rated as level 1, 6 were rated as level 2, and 16 as level 3. Methodologic limitations in these studies would tend to exaggerate the risk for VTE with OC use. For HRT studies (n = 9), the pooled risk ratios (95% confidence intervals) in case-control studies, prospective cohort studies and randomized controlled trials were 2.4 (1.7-3.5), 1.7 (1.0-2.9), and 0.7 (0.3-1.6), respectively. No study was rated as level 1, 6 were rated as level 2, and 3 as level 3. CONCLUSIONS: First, an association between OC use and VTE is likely valid, but the reported risks are probably exaggerated. We estimate that users of non-third-generation OCs have a less than 3-fold increase in the risk for VTE compared with nonusers; the risk for VTE is possibly higher with the use of third-generation OCs. Second, an association between HRT use and VTE might exist; however, further investigation is required before definitive conclusions can be made.

The effects of long-term heparin therapy during pregnancy on bone density. A prospective matched cohort study.

We performed a prospective matched cohort study to investigate the effects of long-term (> 1 month) heparin therapy on lumbar spine bone density. Twenty-five women who received heparin during pregnancy, and 25 matched controls underwent dual photon absorptiometry of the lumbar spine in the post-partum period. Zero of 25 heparin-treated patients developed fractures. Heparin-treated patients had a 0.082 g/cm2 lower bone density compared to untreated controls, which is clinically and statistically significant (p = 0.0077). There were 6 matched pairs in which only the heparin-treated patient had a bone density below 1.0 g/cm2, compared to only one pair in which only the control patient had a bone density below this level (p = 0.089). The correlation coefficients of the difference in bone density in each matched pair, and the duration of heparin therapy, the mean daily dose, and the total dose of heparin were 0.042, - 0.015, and 0.021, respectively; none of these values is statistically significant. We conclude: 1) long-term heparin therapy was associated with a significant reduction in bone density, although fractures are uncommon, 2) there was no significant correlation between lumbar bone density and the dose or duration of heparin.

Interactive conference voting. The OMERACT II Committee. Outcome Measures in Rheumatoid Arthritis Clinical Trial Conference.

We describe and analyze opinion polling results from interactive voting procedures undertaken before and after presentations during the Outcome Measures in Rheumatoid Arthritis Clinical Trials Conference (OMERACT II) in Ottawa, Canada, June 30-July 2, 1994. The scoring procedure was a matched voting design; when a participant used the same keypad at the beginning and end of voting, change within a participant could be estimated. Participants, experienced in the rheumatic diseases included clinicians, researchers, methodologists, regulators, and representatives of the pharmaceutical industry. Patients under consideration were those with any rheumatic diseases. Questions were constructed to evaluate the change in voting behavior expected from the content of the presentation. Statistically significant and substantively important changes were evident in most questions.