Mediators of the association between psychotic experiences and future non-suicidal self-injury and suicide attempts: results from a three-wave, prospective adolescent cohort study.

Psychotic experiences (PEs) are robustly associated with subsequent non-suicidal self-injury (NSSI) and suicide attempts, but questions remain as to the temporal relation and underlying cause of this association. Most investigations have incorporated only two waves of data, and no study has comprehensively investigated mediating pathways. This study aimed to investigate both the PE-NSSI and PE-suicide attempt association, and their relevant mediators, across three waves of prospective data. Participants were from an Australian prospective longitudinal cohort of 1100 adolescents (12-17 years); data were collected at three time points over 2 years. NSSI and suicide attempts were measured using the Self-Harm Behaviour Questionnaire. Items from the Diagnostic Interview Schedule for Children were used to assess four PE subtypes (auditory hallucinatory experiences [HEs] and three delusional experiences). Potential mediators of interest included: psychological distress, self-reported mental disorders, self-esteem, recent traumatic life events (e.g. bullying, sexual assault), emotion regulation, and impulsivity/other personality traits. Analyses were adjusted for sociodemographics and substance use. Auditory HEs were indirectly associated with future NSSI and suicide attempts via recent traumatic life events, high psychological distress, and low self-esteem, across three waves of data. Other PE subtypes were generally not associated with incident NSSI/suicide attempts at 1- and 2-year follow-up, either directly or indirectly. These findings highlight the importance of screening for auditory HEs when assessing a young person's self-harm/suicide risk. Clinical assessment would be further enhanced by a comprehensive review of recent interpersonal traumatic events, as well as levels of self-esteem and distress.

Can't get you out of my head: Persistence and remission of psychotic experiences in adolescents and its association with self-injury and suicide attempts.

BACKGROUND: Persistent psychotic experiences (PEs) may increase risk for mental disorders, non-suicidal self-injury (NSSI), and suicide attempts, relative to PEs that are more transient and remitting in nature. Most investigations of PE persistence have incorporated only two waves of data, and have not investigated the persistence of different PE subtypes and their association with future NSSI and suicide attempts. This study aimed to investigate the association between PE persistence, NSSI, and suicide attempts using three waves of prospective data. A secondary aim was to investigate potential reverse pathways where self-injurious behaviour (and its persistence) instead precedes subsequent PE occurrence. METHOD: Participants were 1100 adolescents (12-17 years) from an Australian prospective cohort study; with three time points over two years. The Self-Harm Behaviour Questionnaire was used to assess NSSI and suicide attempts. Four PE subtypes (auditory hallucinatory experiences [HEs], and three delusional experiences) were assessed using the Diagnostic Interview Schedule for Children. Logistic regression analyses were conducted where PEs was grouped into five categories according to their persistence across the three waves of data. Analyses were adjusted for sociodemographics and substance use. RESULTS: Overall, persistence of PEs (with endorsement of PE across two or three waves) was associated with the highest risk of incident NSSI and suicide attempts at 1- and 2-year follow-up (OR range: 2.57-12.25), whereas remitted PEs (with endorsement of PE at baseline only) were not associated with increased risk of future NSSI or suicide attempts. This pattern of association was evident for auditory HEs but not for most other PE subtypes; although some estimates had wide confidence intervals. There was no support for reverse temporality. CONCLUSION: Our findings support and extend the two-wave cohort literature demonstrating that PEs which persist over time are more robust predictors of future NSSI and suicidal behaviour. Auditory HEs that are persisting in nature are an important but under-recognised risk factor for NSSI and suicide attempts during adolescence, and current findings should inform clinical guidelines into the predictors of self-harm and suicide risk at this life stage.

A comparison of hallucinatory experiences and their appraisals in those with and without mental illness.

Few studies have compared the content and appraisal of hallucinatory experiences (HE) by people with psychosis and those without. This study compared the characteristics of HE, and their appraisals, in individuals with psychotic disorder, non-psychotic mental disorder and no disorder in the general population. Participants (n = 253) aged between 30-33 years who reported HE were recruited from a birth cohort and assessed for lifetime diagnoses of mental disorders. They were allocated to groups based on their diagnosis and their HE were rated to assess their form, content and associated appraisals. Compared to those with no mental disorder, participants with a psychotic disorder had almost twelve times the odds of appraising their HE as distressing and dangerous and nine times the odds of experiencing recurrent HE. Those with a non-psychotic disorder had more than twice the odds of recurrent HE compared to those with no disorder. Overall, HE showed more similarities than differences across the diagnostic groups. Negative appraisals of HE and their recurrence differentiated clinical from non-clinical populations. Screening for HE and assessment of their associated appraisals is essential in those seeking care for mental health difficulties. Interventions aimed at modifying maladaptive appraisals can assist in reducing hallucination related distress.

Association between psychotic experiences and non-accidental self-injury: results from a nationally representative survey of adolescents.

PURPOSE: The association between psychotic experiences (PEs) and non-accidental self-injury (NASI; including self-harm and suicide attempts) is well established, although variables influencing this relationship have not been comprehensively examined. This study aimed to investigate (1) the cross-sectional PE-NASI association before and after adjustment for confounders, and (2) the individual contribution of each confounding and potentially mediating variable to the association. METHODS: A random sample of Australian adolescents aged 14-17 years (n = 1998) completed self-report questions regarding any self-harm, suicidality or PEs experienced in the past 12 months in 2013-2014 as part of the Young Minds Matter Survey, a national household survey. We conducted logistic regression analyses to investigate the association between NASI and PEs, after controlling for confounders (sociodemographics, substance use, and parental mental illness) as well as the influence of potential mediators (major depression, bullying, psychological distress, sleep, self-esteem, disordered eating behaviour, social isolation, and intervention factors). RESULTS: Except for special messages, all PE subtypes (auditory and visual hallucinatory experiences [HEs], and two of the three delusional experiences [DEs]) were associated with NASI after adjustment for confounders (OR range: 2.60-5.21). Depression and psychological distress significantly influenced all PE-NASI associations, where depression appeared to fully explain the DE-NASI association, and partially attenuate the HE-NASI association. Variables such as parental mental illness, disordered eating behaviour, and social isolation had negligible effects in nearly all self-harm and attempted suicide models. CONCLUSIONS: Adolescents reporting any PE in the past 12 months reported increased likelihood of NASI in the same time period and, auditory HEs in particular, were strongly and independently associated with self-harm and suicide attempts. These results highlight the importance of PEs as indicators of risk of self-injurious behaviour among Australian youth.

Prevalence and correlates of psychotic experiences in a nationally representative sample of Australian adolescents.

OBJECTIVE: Despite growing literature on psychotic experiences, no nationally representative study has reported on the prevalence of both hallucinatory experiences and delusional experiences in Australian adolescents. Also, while many studies have examined the association between psychotic experiences and certain demographic and clinical correlates, there are more variables of interest to be investigated, including disordered eating behaviour and hours of sleep. The aims of this study were to examine (1) the prevalence of hallucinatory experiences and delusional experiences in Australian adolescents, and (2) the associations between different types of psychotic experiences with a broad range of demographic, clinical, and psychosocial variables. METHODS: A random sample of Australian adolescents aged 14- to 17-year-olds were recruited in 2013-2014 as part of the Young Minds Matter Survey. Participants completed self-report questions regarding five different psychotic experience types (auditory and visual hallucinatory experiences, and thoughts read, special messages, spied upon) experienced in the past 12 months. Using logistic regression analyses, we investigated associations between psychotic experiences and demographic, clinical, and psychosocial factors. RESULTS: The 12-month prevalence ranged from 3.3% (95% confidence interval = [2.6, 4.3]) for special messages to 14.0% (95% confidence interval = [12.3, 15.8]) for auditory hallucinatory experiences. At the bivariate level, each psychotic experience subtype was associated with increased likelihood of major depression, being bullied, psychological distress, low self-esteem, mental health service use and insufficient sleep (<8 hours per night). Multivariate analyses revealed both auditory and visual hallucinatory experiences were associated with an increased likelihood of four of these variables (depression, being bullied, service use, insufficient sleep), whereas associations with delusional experiences were inconsistent. CONCLUSION: Hallucinatory and delusional experiences are common in Australian adolescents. Hallucinatory experiences, rather than delusional experiences, may be more clinically relevant in this demographic. When psychotic experiences are endorsed by adolescents, further assessment is indicated so as to ascertain more detail on the phenomenology of the experiences to better understand their clinical relevance.

Nineteen and Up study (19Up): understanding pathways to mental health disorders in young Australian twins.

PURPOSE: The Nineteen and Up study (19Up) assessed a range of mental health and behavioural problems and associated risk factors in a genetically informative Australian cohort of young adult twins and their non-twin siblings. As such, 19Up enables detailed investigation of genetic and environmental pathways to mental illness and substance misuse within the Brisbane Longitudinal Twin Sample (BLTS). PARTICIPANTS: Twins and their non-twin siblings from Queensland, Australia; mostly from European ancestry. Data were collected between 2009 and 2016 on 2773 participants (age range 18-38, 57.8% female, 372 complete monozygotic pairs, 493 dizygotic pairs, 640 non-twin siblings, 403 singleton twins). FINDINGS TO DATE: A structured clinical assessment (Composite International Diagnostic Interview) was used to collect lifetime prevalence of diagnostic statistical manual (4th edition) (DSM-IV) diagnoses of major depressive disorder, (hypo)mania, social anxiety, cannabis use disorder, alcohol use disorder, panic disorder and psychotic symptoms. Here, we further describe the comorbidities and ages of onset for these mental disorders. Notably, two-thirds of the sample reported one or more lifetime mental disorder.In addition, the 19Up study assessed general health, drug use, work activity, education level, personality, migraine/headaches, suicidal thoughts, attention deficit hyperactivity disorder (ADHD) symptomatology, sleep-wake patterns, romantic preferences, friendships, familial environment, stress, anorexia and bulimia as well as baldness, acne, asthma, endometriosis, joint flexibility and internet use.The overlap with previous waves of the BLTS means that 84% of the 19Up participants are genotyped, 36% imaged using multimodal MRI and most have been assessed for psychological symptoms at up to four time points. Furthermore, IQ is available for 57%, parental report of ADHD symptomatology for 100% and electroencephalography for 30%. FUTURE PLANS: The 19Up study complements a phenotypically rich, longitudinal collection of environmental and psychological risk factors. Future publications will explore hypotheses related to disease onset and development across the waves of the cohort. A follow-up study at 25+years is ongoing.

A randomized waitlist control community study of Social Cognition and Interaction Training for people with schizophrenia.

OBJECTIVE: Social Cognition and Interaction Training (SCIT) has demonstrated effectiveness in improving social cognition and functioning of people with schizophrenia. This pilot study examines the acceptability, feasibility, and effectiveness of SCIT with individuals who have schizophrenia-spectrum disorders and are receiving care through a public mental health service. METHOD: In a pragmatic randomized waitlist controlled trial, 36 participants (aged 19-55 years) with a schizophrenia spectrum disorder were randomly allocated to SCIT or treatment as usual (TAU). Measures of theory of mind, emotion perception, attributional bias, social skills, quality of life, life skills, depression, anxiety, and stress were administered pre- and post-intervention with follow-up conducted 4 months later. All wait-list controls subsequently received the intervention and a secondary within-group analysis was conducted including these participants. RESULTS: While no significant differences were found between groups on any outcomes, there was strong engagement with the SCIT intervention. Of the 21 participants in the intervention group, the completion rate was 85.71% with a median attendance rate of 17 sessions. Within subject analyses of SCIT participants over time showed significant improvements in quality of life, emotion recognition, social skills, and a trend towards better life skills from pre- to post-intervention. These gains were sustained at the 4-month follow-up time. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Although this study showed limited benefits in outcomes associated with SCIT compared with TAU, it demonstrated the acceptability of SCIT to participants in a real world public health setting shown by high retention, attendance, and positive feedback. This pilot shows SCIT can be implemented in routine clinical practice and lays the foundation for a larger pragmatic study. PRACTITIONER POINTS: SCIT can be implemented successfully in a real-world community mental health setting. SCIT had high levels of acceptability to these participants. Limitations The small sample size meant there was insufficient power to detect differences between groups on outcome measures. The study did not include measures of psychiatric symptoms or neuropsychological functioning which may have influenced participants' capacity to benefit from SCIT.

Hallucinations in adolescents and risk for mental disorders and suicidal behaviour in adulthood: Prospective evidence from the MUSP birth cohort study.

BACKGROUND: Hallucinations, once equated with serious mental disorders, are common in adolescents. Given the high prevalence of hallucinations, it is important to determine if they are associated with adverse mental health outcomes in adulthood. This study compared the mental health outcomes of participants (aged 30-33years) in the Mater-University of Queensland Study of Pregnancy (MUSP) who reported hallucinations at (a) 14years only and (b) 14 and 21years versus cohort members without hallucinations. METHOD: Participants (n=333) were aged between 30 and 33years and (a) reported hallucinations on the Youth Self-Report Questionnaire at 14 and/or the Young Adult Self-Report Questionnaire at 21years and (b) controls (n=321) who did not report hallucinations. Lifetime diagnoses of mental disorders were ascertained by the Structured Clinical Interview for DSM Disorders (DSM IV-TR) administered by clinical psychologists. Suicidal behaviour was measured by self report. RESULTS: Hallucinations at 14years only were not associated with an increased risk of mental disorders in adulthood. Hallucinations reported at both 14 and 21years were associated with lifetime diagnoses of psychotic disorders (OR, 8.84; 95% CI: 1.61-48.43 and substance use disorders (OR, 2.34; 95% CI: 1.36-4.07) and also strongly associated with lifetime suicide attempts (OR, 7.11; 95% CI: 2.68-18.83). CONCLUSIONS: Most adolescents who experience hallucinations do not have an increased rate of mental disorder in adulthood; however, those with hallucinations that are experienced at more than one point in time are at increased risk of suicidal behaviour and both psychotic and non-psychotic psychopathology.

Age at first tobacco use and risk of subsequent psychosis-related outcomes: A birth cohort study.

OBJECTIVE: Compared to the substantial body of research examining links between cannabis use and psychosis, there has been relatively little attention to the role of tobacco as a potential risk factor for psychosis. This study explored the association between age at first tobacco use and psychosis-related outcomes in a birth cohort. METHOD: This study is based on a large birth cohort (the Mater-University Study of Pregnancy). At approximately 21 years of age, cohort members (N = 3752) were assessed for three psychosis-related outcomes (International Classification of Diseases non-affective psychosis, the presence of any hallucination and total count of delusional-like experiences) with the Composite International Diagnostic Interview and the Peters Delusional Inventory. Associations between age at first tobacco use and psychosis-related outcomes were examined using logistic regression in a model (a) adjusted for sex and age and (b) in a second model excluding all respondents who had a history of past problematic and current cannabis use. RESULTS: When adjusted for age and sex, those who commenced tobacco at 15 years of age or younger were significantly more likely to (a) have non-affective psychosis, (b) be in the highest quartile of total score of the Peters Delusional Inventory and (c) report hallucinations. After excluding all those with a history of a cannabis use disorder, or who were current (last month) cannabis users, a significant association between age at first tobacco use and the presence of hallucinations persisted. CONCLUSION: There is an association between age at first tobacco use and subsequent psychosis-related outcomes in young adults. While the findings cannot be used to deduce causality, it adds weight to the hypothesis that early tobacco use may contribute to the risk of developing psychosis-related outcomes.

Development and pilot feasibility study of a health information technology tool to calculate mortality risk for patients with asymptomatic carotid stenosis: the Carotid Risk Assessment Tool (CARAT).

BACKGROUND: Patients with no history of stroke but with stenosis of the carotid arteries can reduce the risk of future stroke with surgery or stenting. At present, a physicians' ability to recommend optimal treatments based on an individual's risk profile requires estimating the likelihood that a patient will have a poor peri-operative outcomes and the likelihood that the patient will survive long enough to gain benefit from the procedure. We describe the development of the CArotid Risk Assessment Tool (CARAT) into a 2-year mortality risk calculator within the electronic medical record, integrating the tool into the clinical workflow, training the clinical team to use the tool, and assessing the feasibility and acceptability of the tool in one clinic setting. METHODS: We modified an existing clinical flowsheet with the local electronic medical record for the CARAT risk model. To understand how CARAT would fit into the existing clinical workflow, we observed the clinic and talked with the clinical staff to develop a process map for the existing clinical workflow. CARAT was completed by the clinic nurse for patients identified on the clinic schedule as having carotid narrowing. We analyzed post-implementation assessment in two ways: quantifying the proportion of eligible patients with whom CARAT was utilized, and surveying surgeons to understand the impact of CARAT on decision-making and clinical workflow. RESULTS: With minimum investment of institutional resources, we were able to produce a workable tool and pilot the tool in our clinic within a 6 month time period. Over 4 months, 287 patients were seen in the clinic with carotid narrowing, and clinic staff completed CARAT for 195 (68%). Per-surgeon completion rates ranged from 29 to 81%. Most patients (191 of 195, 98%) patients had a low 2-year calculated mortality risk. Most surgeons believed the risk assessment aligned with their expectations of patient predicted risk. CONCLUSIONS: We successfully integrated CARAT into the existing electronic medical record and have preliminary evidence that CARAT can be a valuable tool for evaluating mortality risk for patients with diseased carotid arteries. Accuracy of the risk calculations must be evaluated in larger, multi-center studies.

Recovery from first-episode psychosis: a dialogical perspective.

This study aims to understand the process of change in self and its relationship to recovery in the first 3 months following first-episode psychosis (FEP). Because psychosis is understood as a disorder of self, theories of self are needed to consider how sense of self is affected and restored. The authors used semistructured interviews to explore the experiences of 12 young people who had been diagnosed with FEP. The interviews were conducted at two time points: during the first month following the onset of psychosis and 3 months later. The authors employed Interpretive Phenomenological Analysis to explicate interview data and explore the experience of change following FEP. Themes that emerged in the data came under two superordinate themes: loss of self and strengthening of self. Dialogical theory of self was used to interpret the findings and explore the relationship between sense of self and recovery for young people during this critical phase following FEP.

The prevalence and correlates of childhood trauma in patients with early psychosis.

OBJECTIVE: To describe the prevalence and demographic, clinical and functional correlates of childhood trauma in patients attending early psychosis clinics. METHOD: Participants were recruited from outpatients attending four early psychosis services. Exposure to childhood trauma was assessed using the Childhood Trauma Questionnaire (CTQ). Psychopathology was measured using the Positive and Negative Syndrome Scale and the Depression, Anxiety and Stress Scale. Social and vocational functioning and substance use were also assessed. RESULTS: Over three-quarters of the 100 patients reported exposure to any childhood trauma. Emotional, physical and sexual abuse were reported by 54%, 23% and 28% of patients, respectively, while 49% and 42% of patients reported emotional and physical neglect, respectively. Female participants were significantly more likely to be exposed to emotional and sexual abuse. Exposure to childhood trauma was correlated with positive psychotic symptoms and higher levels of depressive, anxiety and stress symptoms; however, it had no impact on social or vocational functioning or recent substance use. CONCLUSION: Exposure to childhood trauma was common in patients with early psychosis, and associated with increased symptomatology. Existing recommendations that standard clinical assessment of patients with early psychosis should include inquiry into exposure to childhood trauma are supported.

Recovery from first-episode psychosis and recovering self: A qualitative study.

OBJECTIVE: The objective of this study was to explore the subjective factors associated with the experience of first-episode psychosis (FEP) and the very first stages of recovery to develop our understanding of this process and improve treatment outcomes. METHOD: Interpretive Phenomenological Analysis was used to explore the experiences of 20 young people who had recently experienced FEP. RESULTS: Two broad superordinate themes captured essential thematic trends in the data: experiences of self-estrangement and self-consolidation. The concept of dialogical self was used to understand the effect of psychosis on self and the process of resuming familiar social positions to facilitate recovery. The concept of making meaning after traumatic events was also applied to the narratives of personal growth that participants formed. Those who reported subjective improvements in recovery were more likely to have developed a meaningful interpretation of their psychosis, strengthened relationships with others, and forged a stronger sense of self. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The experience of self-consolidation was strongly associated with the person's resumption of familiar social roles and their ability to make meaning from their experience in a way that promoted personal growth. Although these processes are known to be part of personal recovery, this study highlights their importance in the very early stages of recovery immediately after the experience of FEP.

Auditory verbal hallucinations in persons with and without a need for care.

Auditory verbal hallucinations (AVH) are complex experiences that occur in the context of various clinical disorders. AVH also occur in individuals from the general population who have no identifiable psychiatric or neurological diagnoses. This article reviews research on AVH in nonclinical individuals and provides a cross-disciplinary view of the clinical relevance of these experiences in defining the risk of mental illness and need for care. Prevalence rates of AVH vary according to measurement tool and indicate a continuum of experience in the general population. Cross-sectional comparisons of individuals with AVH with and without need for care reveal similarities in phenomenology and some underlying mechanisms but also highlight key differences in emotional valence of AVH, appraisals, and behavioral response. Longitudinal studies suggest that AVH are an antecedent of clinical disorders when combined with negative emotional states, specific cognitive difficulties and poor coping, plus family history of psychosis, and environmental exposures such as childhood adversity. However, their predictive value for specific psychiatric disorders is not entirely clear. The theoretical and clinical implications of the reviewed findings are discussed, together with directions for future research.

Successful recruitment to a study of first-episode psychosis by clinicians: a qualitative account of outcomes and influences on process.

UNLABELLED: Abstract Background: Strategies proposed to promote recruitment of representative samples to trials and mental health research have focused on researchers external to clinical services. How clinicians approach recruitment as researchers and particularities of recruiting people with first episode of psychosis warrant investigation. AIMS: To describe recruitment, by clinicians, of people with first-episode psychosis (FEP) and factors influencing process and enrolment. METHODS: Observational study nested within longitudinal examination of trauma and outcomes for patients experiencing first psychotic episode. Data collected during 20 scheduled meetings of clinicians recruiting from services in Australia. RESULTS: Timely recruitment of 60 young people demonstrates that clinicians can successfully engage patients in research. Success depends on satisfaction of organisational preconditions and clinician motivation grounded in considering the study worthwhile. Pre-selection of participants was informed by judgments about health, insight and quality of the therapeutic alliance. Patients' decisions were influenced by family support, acceptance of diagnosis and altruism. Honoraria had variable effect. CONCLUSIONS: Clinicians are well placed to recruit when appropriately supported, and people with FEP are willing to engage in research that fits their personal circumstances. Research should examine the meaning of participation in such studies and ways participation could support recovery.

Can employment positively affect the recovery of people with psychiatric disabilities?

OBJECTIVE: This study explored the relationship between employment and recovery in individuals with psychiatric disabilities and proposed that participants who were employed would have higher levels of recovery than participants who were not employed. METHODS: Data were analysed from a pre-existing data-set produced in a large scale NHMRC project conducted as part of the Australian Integrated Mental Health Initiative (AIMhi), High Support Stream. Participants were 344 people with a range of psychiatric illnesses who received support from 11 public sector and non-government mental health organizations in Queensland and New South Wales, Australia. Scores on the Recovery Assessment Scale (RAS) were compared between those participants who were engaged in paid employment and those who were not. RESULTS: The results revealed that there was no difference in total recovery scores between those who worked and those who did not work. This finding indicated that higher recovery scores were not associated with participants who were employed. Also contrary to expectations, the results showed that workers scored lower than non-workers on the RAS factor described as "reliance on others" and there was a trend towards significance in the same direction on the factor "willingness to ask for help." CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Further research needs to be conducted to determine if the differences between workers and non-workers on the above factors represent a personal variable such as independence or self-determination that is associated with individuals with psychiatric disabilities that are engaged in employment. Rehabilitation interventions aimed at increasing levels of employment in people with psychiatric disabilities could improve recovery and employment outcomes through focusing on these personal variables.

Delaying second births among adolescent mothers: a randomized, controlled trial of a home-based mentoring program.

CONTEXT: Rates of rapid second births among low-income black adolescent mothers range from 20% to 50%. Most efforts to prevent rapid second births have been unsuccessful. OBJECTIVES: There were 4 objectives: (1) to examine whether a home-based mentoring intervention was effective in preventing second births within 2 years of the adolescent mother's first delivery; (2) to examine whether greater intervention participation increased the likelihood of preventing a second birth; (3) to examine whether second births were better predicted from a risk practice perspective or a family formation perspective, based on information collected at delivery; and (4) to examine how risk practices or family formation over the first 2 years of parenthood were related to a second birth. DESIGN: We conducted a randomized, controlled trial of a home-based intervention curriculum, based on social cognitive theory, and focused on interpersonal negotiation skills, adolescent development, and parenting. The curriculum was delivered biweekly until the infant's first birthday by college-educated, black, single mothers who served as mentors, presenting themselves as "big sisters." The control group received usual care. Follow-up evaluations were conducted in the homes 6, 13, and 24 months after recruitment. METHODS: Participants were recruited from urban hospitals at delivery and were 181 first time, black adolescent mothers (< 18 years of age); 82% (149 of 181) completed the 24-month evaluation. RESULTS: Intent-to-treat analyses revealed that control mothers were more likely than intervention mothers to have a second infant. The complier average causal effect was used to account for variability in intervention participation. Having > or = 2 intervention visits increased the odds of not having a second infant more than threefold. Only 1 mother who completed > or = 6 visits had a second infant. At delivery of their first infant, mothers who had a second infant were slightly older (16.7 vs 16.2 years) and were more likely to have been arrested (30% vs 14%). There were no differences in baseline contraceptive use or other measures of risk or family formation. At 24 months, mothers who had a second infant reported high self-esteem, positive life events, and romantic involvement and residence with the first infant's father. At 24 months, there were no differences in marital rates (2%), risk practices, or contraceptive use between mothers who did and did not have a second infant. Mothers who did not have a second infant were marginally more likely to report no plans for contraception in their next sexual contact compared with mothers who had a second infant (22% vs 8%, respectively). CONCLUSIONS: A home-based intervention founded on a mentorship model and targeted toward adolescent development, including negotiation skills, was effective in preventing rapid repeat births among low-income, black adolescent mothers. The effectiveness of the intervention could be seen after only 2 visits and increased over time. There were no second births among mothers who attended > or = 8 sessions. There was no evidence that risk behavior or contraceptive use was related to rapid second births. There was some evidence that rapid second births among adolescent mothers were regarded as desirable and as part of a move toward increasing autonomy and family formation, thereby undermining intervention programs that focus on risk avoidance. Findings suggest the merits of a mentoring program for low-income, black adolescent mothers, based on a relatively brief (6-8 sessions) curriculum targeted toward adolescent development and interpersonal negotiation skills.

Parental perceptions of infant vulnerability in a preterm sample: prediction from maternal adaptation to parenthood during the neonatal period.

The present longitudinal study of African-American mothers of preterm infants tested the hypothesis that the quality of maternal adaptation to parenthood before infant discharge from the hospital is predictive of maternal perceptions of infant vulnerability later in the infant's first year. As hypothesized, perceptions of infant vulnerability at 3 to 4 months of infant corrected age were predicted by two theoretically relevant measures of maternal adaptation in the neonatal period: mothers' perceptions of their neonates as lethargic and unresponsive to mothers' bids and by low maternal self-efficacy beliefs about feeding the infant. Neonatally obtained maternal self-inefficacy beliefs about their ability to feed the infant in particular proved to be quite robust in predicting mothers' later perceptions of infant vulnerability. Findings collectively suggest that careful attention to the manner in which mothers of preterm infants adapt to parenthood, even before infant hospital discharge, can help clinicians identify mothers at particularly high risk of developing perceptions of infant vulnerability later in the infant's first year. Implications for intervention are discussed.