Study protocol: How does cognitive flexibility relate to other executive functions and learning in healthy young adults?

BACKGROUND: Cognitive flexibility (CF) enables individuals to readily shift from one concept or mode of practice/thoughts to another in response to changes in the environment and feedback, making CF vital to optimise success in obtaining goals. However, how CF relates to other executive functions (e.g., working memory, response inhibition), mental abilities (e.g., creativity, literacy, numeracy, intelligence, structure learning), and social factors (e.g., multilingualism, tolerance of uncertainty, perceived social support, social decision-making) is less well understood. The current study aims to (1) establish the construct validity of CF in relation to other executive function skills and intelligence, and (2) elucidate specific relationships between CF, structure learning, creativity, career decision making and planning, and other life skills. METHODS: This study will recruit up to 400 healthy Singaporean young adults (age 18-30) to complete a wide range of cognitive tasks and social questionnaires/tasks. The richness of the task/questionnaire battery and within-participant administration enables us to use computational modelling and structural equation modelling to examine connections between the latent constructs of interest. SIGNIFICANCE AND IMPACT: The current study is the first systematic investigation into the construct validity of CF and its interrelationship with other important cognitive skills such as learning and creativity, within an Asian context. The study will further explore the concept of CF as a non-unitary construct, a novel theoretical proposition in the field. The inclusion of a structure learning paradigm is intended to inform future development of a novel intervention paradigm to enhance CF. Finally, the results of the study will be useful for informing classroom pedagogy and the design of lifelong learning policies and curricula, as part of the wider remit of the Cambridge-NTU Centre for Lifelong Learning and Individualised Cognition (CLIC).

The hidden patient: chronic physical morbidity, psychological distress, and quality of life in caregivers of older adults.

AIM: Increasing demands for care provision to older adults require good physical and mental health among caregivers. Few studies have examined the health status and correlates of quality of life among caregivers of older adults. The present study therefore sought to examine the prevalence of chronic physical conditions, psychological distress, and correlates of physical and mental quality of life among caregivers of older adults (≥60 years) in Singapore. METHODS: Participants were 285 informal caregivers who were providing care to an older relative. Participants were recruited at the Institute of Mental Health, Singapore, and they completed self-report measures on chronic physical morbidity, psychological distress, and physical and mental quality of life. Multiple regression models were constructed to examine correlates of physical and mental quality of life. RESULTS: More than half of the caregivers had at least one chronic physical condition (58.6%) and psychological distress (52.6%). Chronic physical morbidity, psychological distress, and secondary education status were associated with lower physical quality of life. Psychological distress, younger age, primary education status, and more time spent caregiving were associated with lower mental quality of life. CONCLUSION: Poor physical and mental health among caregivers may impair their ability to provide adequate care to older adults with progressive medical needs. It is important for medical practitioners not to neglect the physical and mental health of caregivers through continued assessment of chronic physical morbidity, psychological distress, and quality of life.

Deliberate Self-Harm in Psychiatric Outpatients Aged 14-35 Years in Singapore.

INTRODUCTION: The main aim of the study was to identify the prevalence of deliberate self-harm (DSH) in a sample of youth outpatients attending the state psychiatric hospital in Singapore and to identify the sociodemographic and psychological/clinical risk factors associated with DSH. The secondary aim of  the study was to examine if different forms of DSH had distinguishing risk factors. MATERIALS AND METHODS: A total of 400 outpatients at the Institute of Mental Health completed a self-report survey comprising sociodemographic questions, the Functional Assessment of  Self-Mutilation, Childhood Trauma Questionnaire, Parental Bonding Instrument and the Patient Health Questionnaire Depression Scale. Logistic regression models were used to test the associations. RESULTS: The overall prevalence of DSH in our clinical population was 58.8%. Cutting/carving (25.4%) and hitting (20.4%) were the most common forms of DSH in the past 12 months. DSH acts were performed primarily for emotion regulation purposes. The risk factors for DSH in general were younger age group, female gender, abuse history and higher depression scores. Gender and age group were the factors that were differentially associated with cutting and hitting one's self. CONCLUSION: There was a high prevalence of DSH in the psychiatric outpatient population. The risk factors identified in this study are consistent with those of international studies which point to their stability across cultures.

Positive Caregiving Characteristics as a Mediator of Caregiving Burden and Satisfaction With Life in Caregivers of Older Adults.

BACKGROUND: Satisfaction with life is recognized to be a factor in alleviating burden in stressful caregiving duties. However, the mechanism underlying this relationship is indistinct. Positive aspects of caregiving (PAC) may help to regulate caregiving burden among caregivers of older adults. The study aims to examine whether positive caregiving characteristics mediate the effect between satisfaction with life and burden of care. METHODS: Participants were 285 caregivers of older adults (aged 60 and above) in Singapore and were recruited in a cross-sectional, self-report study (mean [M] = 47.0 years; 64.6% females). Measures included in the study were the Zarit Burden Interview (ZBI), Positive Aspects of Caregiving (PAC), and the Satisfaction with Life Scale (SWLS). Mediation analyses were used to study the indirect effects of life satisfaction on caregiver burden through features of PAC. RESULTS: Mean scores for the ZBI, PAC, and SWLS scales were M = 23.15 (standard deviation [SD] = 15.98), M = 34.55 (SD = 8.19), and M = 23.56 (SD = 6.62) respectively. Results from the mediation analysis revealed that the association between life satisfaction and caregiving burden was significantly mediated by the PAC ( P < .001). DISCUSSION: Positive aspects of caregiving may be a mechanism that links satisfaction with life and caregiver burden. Findings may represent attempts to manage caregiving duties as well as maintaining a positive attitude toward their responsibilities.

Resilience and burden in caregivers of older adults: moderating and mediating effects of perceived social support.

BACKGROUND: The burden of caring for an older adult can be a form of stress and influence caregivers' daily lives and health. Previous studies have reported that resilience and social support play an important role in reducing physical and psychological burden in caregivers. Thus, the present study aimed to examine whether perceived social support served as a possible protective factor of burden among caregivers of older adults in Singapore using moderation and mediation effects' models. METHODS: We conducted a cross-sectional study with 285 caregivers providing care to older adults aged 60 years and above who were diagnosed with physical and/or mental illness in Singapore. The Connor-Davidson Resilience Scale (CD-RISC) was used to measure resilience and burden was measured by the Zarit Burden Interview (ZBI). The Multidimensional Scale of Perceived Social Support (MSPSS) was used to measure perceived social support. Hayes' PROCESS macro was used to test moderation and mediation effects of perceived social support in the relationship between resilience and burden after controlling for sociodemographic variables. Indirect effects were tested using bootstrapped confidence intervals (CI). RESULTS: The mean scores observed were CD-RISC: 70.8/100 (SD = 15.1), MSPSS: 62.2/84 (SD = 12.2), and ZBI: 23.2/88 (SD = 16.0) respectively. While perceived social support served as a full mediator between resilience and caregiver burden (ß = - 0.14, 95% CI -0.224 to - 0.072, p < 0.05), it did not show a significant moderating effect. CONCLUSIONS: Perceived social support mediates the association between resilience and caregiver burden among caregivers of older adults in Singapore. It is crucial for healthcare professionals, particularly those who interact and deliver services to assist caregivers, to promote and identify supportive family and friends' network that may help to address caregiver burden.

Hazardous alcohol use among patients with schizophrenia and depression.

AIMS: The current study aimed to 1) report the prevalence of hazardous alcohol use in an outpatient population among those with schizophrenia and depressive disorders, 2) assess the sociodemographic and clinical correlates of hazardous alcohol use, 3) examine the association of hazardous alcohol use with severity of depression, anxiety and smoking, and 4) assess the association of hazardous alcohol use with quality of life. METHODS: Three hundred ten outpatients seeking treatment at a tertiary psychiatric institute with a diagnosis of either schizophrenia spectrum disorder or depressive disorder were included in the study. Patients were assessed for hazardous alcohol use using the Alcohol Use Disorders Identification Test. Information on sociodemographic correlates, clinical history, severity of symptoms of depression and anxiety, as well as quality of life (QOL) was collected. RESULTS: The overall prevalence of hazardous alcohol use among the sample was 12.6%. The prevalence of hazardous alcohol use among patients with depression and schizophrenia was 18.8% and 6.4%, respectively. Compared to those who were students, patients who were gainfully employed or unemployed were more likely to engage in hazardous alcohol use (Odds Ratio (OR) = 5.5 and 7.7, respectively). Patients with depression compared to those with schizophrenia (OR = 11.1) and those who were current smokers compared to those who had never smoked (OR = 14.5) were more likely to engage in hazardous alcohol use. Hazardous alcohol use was associated with lower QOL in the physical health domain (p = 0.002). CONCLUSION: Given the significant prevalence of hazardous alcohol use in this population, routine screening for hazardous alcohol use and brief interventions could be an effective way of managing this comorbidity. There is a need to develop and evaluate culturally appropriate brief interventions based on patient preference in this setting.

Emotion dysregulation as a mechanism linking child maltreatment exposure and self-harm behaviors in adolescents.

Although child maltreatment exposure is a recognized risk factor for self-harm, mechanisms underlying this relationship remain unclear. Self-harm may function as a compensatory strategy to regulate distressing emotions. This cross-sectional study examines if emotion dysregulation mediates between the severity of maltreatment exposure and self-harm, adjusting for demographic variables and depressive symptoms. Participants were 108 adolescent patients recruited from a psychiatric hospital in Singapore (mean age 17.0 years, SD=1.65; 59.3% female). Study measures included the Childhood Trauma Questionnaire (CTQ-SF), Functional Assessment of Self-Mutilation (FASM), Difficulties in Emotion Regulation Scale (DERS), and the Patient Health Questionnaire (PHQ-8). Path analysis was conducted to examine the direct and indirect effects of maltreatment exposure on self-harm via emotion dysregulation, controlling for demographic variables and depressive symptoms. Indirect effects were tested using bootstrapped confidence intervals (CI). Results showed that self-harm was highly prevalent in our sample (75.9%). Emotion dysregulation and depressive symptoms were found to be associated with higher self-harm frequency. In addition, results from path analysis showed that the association between the severity of maltreatment exposure and self-harm frequency was significantly mediated by emotion dysregulation B=0.07, p<0.05, 95% CI [0.02, 0.16]. Thus, emotion dysregulation may be a proximal mechanism linking maltreatment exposure and adolescent self-harm. Notably, self-harm may represent maladaptive attempts to manage emotion dysregulation that may have resulted from maltreatment. Findings from the study have implications for the prevention and treatment of self-harm in maltreated youth.

Body mass index, waist-hip ratio and risk of chronic medical condition in the elderly population: results from the Well-being of the Singapore Elderly (WiSE) Study.

BACKGROUND: The aim of the current study was to establish the prevalence and relationship of Body Mass Index (BMI) and Waist-Hip Ratio (WHR) with chronic health conditions and their associated socio-demographic correlates in the elderly population of Singapore. METHODS: The data was extracted from the Well-being of the Singapore Elderly (WiSE) study, a comprehensive single phase, cross-sectional, population-based, epidemiological study conducted in 2013 among Singaporean residents (n = 2565) aged 60 years and above with a mean age of 72.7 years (range 60 to 105, SD = 9.53). The respondents were assessed with anthropometric measurements including height, weight, BMI, waist circumference, hip circumference and WHR. Participants provided information on their socio-demographic details and chronic health conditions. RESULTS: Prevalence of those who were obese, overweight, normal and underweight based on BMI was 8.7 %, 33.4 %, 52.5 % and 5.5 % respectively. Malays were more likely to be overweight compared to Chinese and Indians, while Malays and Indians were more likely to be obese compared to Chinese. Participants who were never married were less likely to be overweight compared to married. Participants aged 85 years and above were more likely to be underweight compared to those aged 60-75 years. Prevalence of high WHR (above 0.90 for men and 0.80 for women) was 79.8 % and this was more pervasive amongst Indians. Participants who were homemakers were more likely to have high WHR while those with tertiary education tended to have low WHR. Being overweight was associated with hypertension and heart problems, while obesity was associated with hypertension and diabetes, and a high WHR was associated with hypertension and diabetes. There were no significant differences in the other chronic conditions in this elderly population. CONCLUSIONS: This study demonstrates the importance of anthropometric measurements in the elderly and its association with certain chronic physical conditions, indicating their utility in the clinical management of these conditions in the elderly.

Qualitative study of Singaporean youths' perception of antismoking campaigns: what works and what does not.

BACKGROUND: Youths are more likely to rebel against messages perceived to inhibit their independence. In order for antismoking campaigns to be effective with this population, adopting evidence-based strategies is crucial. In this study, we examined youths' reaction to past and ongoing antismoking campaigns, and delineate effective and ineffective components of campaigns as identified by them. METHODS: 12 focus group discussions were conducted with 91 youth smokers aged 15-29 years. Data were analysed using qualitative content analysis. A codebook was derived through an iterative process. The data were coded systematically by three coders, using Nvivo V.10. RESULTS: Fear appeals that had no immediate relevance to youths, and campaigns involving humour or sports/dance activities that distracted youths from the antismoking messages, were deemed ineffective. In contrast, elements identified to be efficacious were: positive tone, low-fear visual images, 'low-controlling language' and a genuine spokesperson. Youth tended to favour campaigns circulating on social media platforms. Importantly, youths voiced a lack of tangible support for their efforts to quit smoking. CONCLUSIONS: Participants expressed a preference towards antismoking messages that were less authoritative, and perceived a distinct lack of support for their intentions to quit smoking. There is room for incorporating suggestions by participants in future antismoking campaigns. Future research is needed to identify barriers to accessing available support.

Perspectives on Smoking Initiation and Maintenance: A Qualitative Exploration among Singapore Youth.

Studies among adolescents have shown that several important interpersonal, intrapersonal and environmental factors are associated with smoking behaviour. The current qualitative research project aimed to explore the determinants of smoking initiation and maintenance, from a youth perspective, among young people who smoked, living in a multi-ethnic Asian country. Focus group discussions (FGDs) were conducted with youths in Singapore in youth-friendly and accessible locations. Young people, from a variety of social contexts-varying on age, gender, ethnicity and educational level, were included in the study. All FGDs were conducted in English and participants were recruited using a mix of network and purposive sampling. All FGDs were audio recorded and transcribed verbatim. The data were analyzed using qualitative content analysis, allowing themes to emerge from the data with the goal of answering the research question. Ninety-one youth smokers (54 males, 37 females), aged between 14 to 29 years, participated in the study. The majority were males (59%) and of Chinese ethnicity (52%). Participants identified multiple personal, social, and familial influences on young adults' smoking behaviors. Peer and family influences, as well as risk minimization, played a key role in smoking initiation and maintenance. While young people were aware of policies that restricted smoking, these did not directly affect their decision to start smoking. The theory of triadic influence provided a promising theoretical framework to understand smoking initiation and maintenance in a sample of young adult smokers from a multi-ethnic Asian country. It also provides actionable information for initiatives to prevent smoking in young people, which includes their perspectives and emphasizes an inclusive approach without stigmatizing those who smoke.