A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of Well Parent Japan in routine care in Japan: The training and nurturing support for mothers (TRANSFORM) study.

BACKGROUND: Well Parent Japan (WPJ) is a new hybrid group parent training programme combining sessions to improve mothers' psychological well-being with a culturally adapted version of the New Forest Parenting Programme (NFPP). This study investigates the effectiveness and cost-effectiveness of WPJ against treatment as usual (TAU) within Japanese child mental health services. METHODS: TRANSFORM was a pragmatic multi-site randomised controlled trial (RCT) with two parallel arms. Altogether 124 mothers of 6-12-year-old children with DSM-5 ADHD were randomised to WPJ (n = 65) or TAU (n = 59). Participants were assessed at baseline, post-treatment and three-month follow-up. The primary outcome was parent-domain stress following intervention. Secondary outcomes included maternal reports of child-domain stress, parenting practices, parenting efficacy, mood, family strain, child behaviour and impairment. Objective measures of the parent-child relationship were collected at baseline and post-treatment. Data analysis was intention to treat (ITT) with treatment effects quantified through analysis of covariance (ANCOVA) via multilevel modelling. An incremental cost-effectiveness ratio (ICER) assessed WPJ's cost-effectiveness. RESULTS: WPJ was superior to TAU in reducing parent-domain stress post-treatment (adjusted mean difference = 5.05, 95% CI 0.33 to 9.81, p = .036) and at follow-up (adjusted mean difference 4.82, 95% CI 0.09 to 9.55, p = .046). Significant WPJ intervention effects were also observed for parenting practices, parenting efficacy and family strain. WPJ and TAU were not significantly different post-intervention or at follow-up for the other secondary outcomes. The incremental cost of WPJ was 34,202 JPY (315.81 USD). The probability that WPJ is cost-effective is 74% at 10,000 JPY (USD 108.30) per one-point improvement in parenting stress, 92% at 20,000 JPY (216.60 USD). The programme was delivered with high fidelity and excellent retention. CONCLUSIONS: WPJ can be delivered in routine clinical care at modest cost with positive effects on self-reported well-being of the mothers, parenting practices and family coping. WPJ is a promising addition to psychosocial interventions for ADHD in Japan.

The Effectiveness and Cost-effectiveness of Well Parent Japan for Japanese Mothers of Children With ADHD: Protocol for a Randomized Controlled Trial.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder associated with numerous functional deficits and poor long-term outcomes. Internationally, behavioral interventions are recommended as part of a multimodal treatment approach for children with ADHD. Currently, in Japan, there are limited interventions available to target ADHD. Well Parent Japan (WPJ), a new hybrid parent-training program, provides a culturally acceptable and effective way to help support Japanese children with ADHD and their parents. OBJECTIVE: This pragmatic multicenter randomized controlled trial aims to provide preliminary evidence about the effectiveness and cost-effectiveness of WPJ evaluated against treatment as usual (TAU) within routine Japanese mental health services. METHODS: Mothers of children (aged 6-12 years) diagnosed with ADHD were recruited from child and adolescent mental health care services at three hospital sites across Japan (Fukui, Fukuoka, and Okinawa). The mothers were randomized to receive immediate treatment or TAU. The effectiveness and cost-effectiveness of WPJ over TAU at the end of the intervention and at 3-month follow-up will be evaluated. The primary outcome is maternal parent domain stress in the parenting role. The following secondary outcomes will be explored: child behavior, including severity of ADHD symptoms; parenting practices; emotional well-being; and the parent-child relationship and maternal child domain parenting stress. Data analysis will follow intention-to-treat principles with treatment effects quantified through analysis of covariance using multilevel modeling. An incremental cost-effectiveness ratio will be used to analyze the cost-effectiveness of the WPJ intervention. RESULTS: Study funding was secured through a proof-of-concept grant in July 2018. Approval by the institutional review board for the data collection sites was obtained between 2017 and 2019. Data collection began in August 2019 and was completed in April 2022. Participant recruitment (N=124) was completed in May 2021. Effectiveness and cost-effectiveness analyses are expected to be completed by July 2022 and December 2022, respectively. These timelines are subject to change owing to the COVID-19 pandemic. CONCLUSIONS: This is the first multisite pragmatic trial of WPJ based on the recruitment of children referred directly to routine clinical services in Japan. This multisite randomized trial tests the effectiveness of WPJ in children and families by comparing WPJ directly with the usual clinical care offered for children diagnosed with ADHD in Japan. We also seek to assess and compare the cost-effectiveness of WPJ with TAU in Japan. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number ISRCTN66978270; https://www.isrctn.com/ISRCTN66978270. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/32693.

Is increased sensitivity to punishment a common characteristic of attention deficit/hyperactivity disorder? An experimental study of response allocation in Japanese children.

Research on motivational processes in attention deficit/hyperactivity disorder (ADHD) focuses on reward. Studies with punishment are limited and findings mixed. This study evaluated the effects of punishment on response allocation in Japanese children with and without ADHD. Thirty-four children meeting DSM-IV criteria for ADHD and 59 typically developing control-group children completed an operant task in which they choose between playing two simultaneously available games. Reward was arranged symmetrically across the games under concurrent variable interval schedules. Asymmetric punishment schedules were superimposed with responses on one game punished four times as often as responses on the other. Children with ADHD showed greater behavioral sensitivity to punishment than controls. They allocated significantly more responses to the less frequently punished alternative and were more likely to play this game on consecutive trials and responded more slowly to the more punished game. Control group children allocated their responses evenly across games. Punishment exerted greater control over the behavior of Japanese children with ADHD than controls, similar to findings with children from Western countries, suggesting this is a common characteristic of the disorder. The behavior of typically developing Japanese children, while demonstrating awareness of punishment, was not controlled by the frequency of its occurrence.

Behavioral sensitivity of Japanese children with and without ADHD to changing reinforcer availability: an experimental study using signal detection methodology.

BACKGROUND: Most research on motivational processes in attention deficit hyperactivity disorder (ADHD) has been undertaken in Western Europe and North America. The extent to which these findings apply to other cultural groups is unclear. The current study evaluated the behavioral sensitivity of Japanese children with and without ADHD to changing reward availability. Forty-one school-aged children, 19 diagnosed with DSM-IV ADHD, completed a signal-detection task in which correct discriminations between two stimuli were associated with different reinforcement frequencies. The response alternative associated with the higher rate of reinforcement switched twice during the task without warning. FINDINGS: Both groups of children developed an initial bias toward the more frequently reinforced response alternative. When the reward contingencies switched the response allocation (bias) of the control group children followed suit. The response bias scores of the children with ADHD did not, suggesting impaired tracking of reward availability over time. CONCLUSIONS: Japanese children with ADHD adjust their behavioral responses to changing reinforcer availability less than their typically developing peers. This is not explained by poor attention to task or a lack of sensitivity to reward. The current results are consistent with altered sensitivity to changing reward contingencies identified in non-Japanese samples of children with ADHD. Irrespective of their country of origin, children with ADHD will likely benefit from behavioral expectations and reinforcement contingencies being made explicit together with high rates of reinforcement for appropriate behaviors.

Adapting an attention-deficit hyperactivity disorder parent training intervention to different cultural contexts: The experience of implementing the New Forest Parenting Programme in China, Denmark, Hong Kong, Japan, and the United Kingdom.

The New Forest Parenting Programme (NFPP) is a parenting program developed for parents who have a child with attention-deficit hyperactivity disorder (ADHD). It is a manualized program that is delivered in a parent's home over 8 weeks, or in a group format, or through a self-help manual. Three randomized controlled trials have been carried out in the United Kingdom. The NFPP group has adapted the program according to feedback from parents and therapists, and for use with different populations, both within the United Kingdom and internationally. The first international trial took place in New York, United States. Trials in Denmark, Hong Kong, and Japan followed. More recently, a trial of the self-help manual has been carried out in mainland China. This paper will outline the adaptions that were needed in order to be able to deliver the program in different countries with their own expectations of parenting, culture, and language. Training had to be differently focused; manuals and handouts had to be revised, translated and back-translated; and supervision had to be delivered at a distance to maintain the fidelity of the program. The international group will outline their experience of running trials in their own countries with the NFPP in a face-to-face format (Denmark), a group format (Hong Kong and Japan), and a self-help format (mainland China).

Floating on Air: Fulfillment and Self-in-Context for Distressed Japanese Women.

This research was part of a larger mixed-methods study examining culture, distress, and help seeking. We surveyed 209 Japanese women living in the United States recruited from clinic and community-based sites, and carried out semi-structured ethnographic interviews with a highly distressed subsample of 25 Japanese. Analytic Ethnography revealed that women described themselves as a "self-in-context," negotiating situations using protective resources or experiencing risk exposure. Women experienced quality of life (QOL) when they were successful. However, a related goal of achievingIkigai(or purpose in life) was differentiated from QOL, and was defined as an ongoing process of searching for balance between achieving social and individual fulfillment. Our resulting hypothetical model suggested that symptom level would be related to risk and protective factors (tested for the full sample) and to specific risk and protective phenomenon (tested in the distressed subsample). Thettests in the full sample found that women who were above threshold for depressive symptoms (n= 26) had higher social stressor and lower social support means. Women who were above the threshold for physical symptoms (n= 99) had higher social stressor means. Analysis of the interviewed subsample found that low self-validation and excessive responsibilities were related to high physical symptoms. We conclude that perceived lack of balance between culturally defined, and potentially opposing, markers of success can create a stressful dilemma for first-generation immigrant Japanese women, requiring new skills to achieve balance. Perceptions of health, as well as illness, are part of complex culturally based interpretations that have implications for intervention for immigrant Japanese women living in the United States.

The Clinical Ethnographic Interview: a user-friendly guide to the cultural formulation of distress and help seeking.

Transcultural nursing, psychiatry, and medical anthropology have theorized that practitioners and researchers need more flexible instruments to gather culturally relevant illness experience, meaning, and help seeking. The state of the science is sufficiently developed to allow standardized yet ethnographically sound protocols for assessment. However, vigorous calls for culturally adapted assessment models have yielded little real change in routine practice. This paper describes the conversion of the Diagnostic and Statistical Manual IV, Appendix I Outline for Cultural Formulation into a user-friendly Clinical Ethnographic Interview (CEI), and provides clinical examples of its use in a sample of highly distressed Japanese women.

Development of a new selective medium for isolation of methicillin-resistant Staphylococcus aureus.

A new selective medium containing cephem antibiotics was developed for isolation of methicillin-resistant Staphylococcus aureus (MRSA). MRSA colonies on a medium containing ceftazidime (CAZ) were most easily identifiable and a medium containing cefoperazone (CPZ) was superior in suppressing the growth of other bacteria. With the medium containing a couple of CAZ and CPZ, MRSA and methicillin-resistant coagulase-negative staphylococci (MRCNS) were detected from 2 and 1 of 15 chicken meat samples respectively. The MRSA and MRCNS recovery test showed that the medium was effective for MRSA isolation, suppressing the growth of other bacteria efficiently. These results suggested that the medium containing a couple of CAZ and CPZ was useful for MRSA detection from foods and animals.