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.

Mental-Physical Multimorbidity in Youth: Associations with Individual, Family, and Health Service Use Outcomes.

Prevalence, correlates, and outcomes of youth with comorbid mental and physical conditions (i.e., multimorbidity) were examined in this cross-sectional study. Participants were 92 youth (14.5 years [SD 2.7]; 69.6% female) and their parents. Mental disorder was assessed using structured interviews and physical health using a standardized questionnaire. Twenty-five percent of youth had multimorbidity and no child or parent demographic or health characteristics were correlated with multimorbidity. Youth with multimorbidity reported similar quality of life and better family functioning [B = - 4.80 (- 8.77, - 0.83)] compared to youth with mental disorder only (i.e., non-multimorbid). Youth with multimorbidity had lower odds of receiving inpatient services [OR = 0.20 (0.05, 0.85)] and shorter stays in hospital for their mental health [OR = 0.74 (0.57, 0.91)] over the past year. Family functioning was found to mediate the association between youth multimorbidity and length of stay [αß = 0.14 (0.01, 0.27)]. Findings reinforce the need for family-centered youth mental health care.

The associations between sex, immigrant status, immigrant concentration and intimate partner violence: evidence from the Canadian General Social Survey.

Intimate partner violence (IPV) is an important public health concern, yet little is known about the combined effects of individual- and neighbourhood-level characteristics on IPV among immigrants. The aim of this study is to examine: (1) the association between immigrant status and IPV victimisation and whether sex modifies this association, and (2) the association between the neighbourhood concentration of immigrants and IPV victimisation, and whether immigrant status modifies this association. Our sample of 10,964 males and females comes from the 2009 Canadian General Social Survey. After controlling for covariates, immigrant status was not associated with IPV, and sex significantly modified the association between immigrant status and financial and physical/sexual IPV. Compared to males, second-generation females were less likely to report financial IPV and first-generation females were more likely to report physical/sexual IPV. Immigrant status modified the association between the neighbourhood concentration of immigrants and emotional and physical/sexual IPV. Compared to third-generation males, first-generation males living in neighbourhoods with a higher concentration of immigrants were more likely to report emotional IPV, whereas second-generation males in these neighbourhoods were less likely to report physical/sexual IPV. Interventions to reduce IPV should pay equal attention to individual- and neighbourhood-level influences.

The role of permanent income and family structure in the determination of child health in Canada.

We use data from the Ontario Child Health Study (OCHS) to provide the first Canadian estimates of how the empirical association between child health and both low-income and family status (lone-mother versus two-parent) changes when we re-estimate the model with pooled data. Two waves of data provide a better indication of the family's long-run level of economic resources than does one wave. Our measures of health status include categorical indicators and the health utility score derived from the Health Utilities Index Mark 2 (HUI2) system. Consistent with findings from other countries, we find that most outcomes are more strongly related to low-average income (in 1982 and 1986) than to low-current income in either year. Unlike some previous research, we find the quantitative impact of low-income on child health to be modest to large. Lone-mother status is negatively associated with most outcomes, but the lone-mother coefficients did not change significantly when we switched from low-current income to low-average income. This implies that the lone-mother coefficient in single cross-sections is not just a proxy for low-permanent income.

Childhood abuse and psychiatric disorders among single and married mothers.

OBJECTIVE: This study examined the prevalence of, and association between, childhood abuse and psychiatric disorders in single and married mothers. METHOD: Single and married mothers who participated in the Ontario Health Survey, a province-wide study derived from a probability sample of the general population of Ontario aged 15 years and older (N=1,471), were included. Sociodemographic and mental health characteristics were collected by means of interviewer-administered questionnaires. A self-administered questionnaire was used to collect information on childhood physical and sexual abuse. RESULTS: Compared with married mothers, single mothers reported substantially lower incomes as well as higher rates of childhood abuse and all psychiatric morbidities examined (current and lifetime affective or anxiety disorders and substance use disorders). Childhood abuse had a consistent and significant association with adult mental health, even when other risk variables were controlled. No interaction among childhood abuse and marital status and outcome was found. CONCLUSIONS: Single mothers reported more childhood abuse and experienced higher levels of poverty and psychiatric disorders than married mothers. Childhood abuse was associated with more psychiatric problems in both single and married mothers. Research, clinical, and policy implications of these findings are discussed.

Evaluation of anti-cocaine antibodies and a cocaine vaccine in a rat self-administration model.

RATIONALE: Previous pre-clinical studies with an anti-cocaine monoclonal antibody left open several issues critical to assessing the effectiveness of a vaccine for altering cocaine self-administration behavior. OBJECTIVES: The objectives of this study were to determine, first, whether changes in self-administration behavior would be systematically related to antibody level and, second, how the antibody affected the self-administration of different doses of cocaine. METHODS: Two experiments were conducted using a second-order schedule of drug delivery in rats. The first was a passive-administration study using the anti-cocaine monoclonal antibody MO240 to examine the relationship between antibody level and cocaine self-administration behavior, and the second was an active-immunization study to examine the efficacy of the cocaine vaccine IPC-1010 for blocking various doses of self-administered cocaine. RESULTS: The passive-administration experiment with control and 4-mg or 12-mg MO240 treatments showed that antagonism of the 1 mg/kg cocaine training dose was dependent on antibody level. In animals whose serum antibody levels were sustained above 0.05 mg/ml, there was a sufficient amount of antibody to reduce drug-seeking behavior and drug intake. In the active-immunization experiment, the cocaine vaccine IPC-1010 induced average serum antibody levels of 0.08 mg/ml and reduced the reacquisition of behavior by 1 mg/kg cocaine. Antagonism of cocaine self-administration after immunization was evident across a range of doses of cocaine and was only apparent in animals whose serum antibody levels exceeded 0.05 mg/ml. Furthermore, there was no evidence that the antagonism was surmountable within the dose range examined (up to 5.6 mg/kg). CONCLUSIONS: Antagonism of cocaine self-administration across a range of doses is feasible after immunization with a cocaine vaccine as long as antibody levels are of a sufficient concentration.

Predicting conduct problems: can high-risk children be identified in kindergarten and grade 1?

Externalizing behavior symptoms (EBS) in childhood are a strong predictor of future conduct problems. This study evaluated their predictive accuracy using logistic regression and receiver operating characteristic curve techniques. EBS, alone and in combination with other child and familial risk factors, were used to predict conduct problems 30 months later in a nonclinic population of kindergartners and Grade 1 children. The sensitivity (Sn) and positive predictive value (PPV) of EBS alone were below preset criteria of > or = 50% for each (prevalence < or = 15%). Sn and PPV increased when other child and familial factors were combined with symptoms but did not exceed the preset criteria. From a developmental perspective, substantial stability of EBS exists over time. However, from the perspective of prevention science, significant levels of misclassification will occur when EBS are used to designate high-risk status under the low-prevalence conditions of normal populations.

Lessening the impact of poverty on children.

The present paper is divided into three sections. The first section deals with two issues: the impact of poverty on children and the hypothesized mechanisms by which poverty affects children. The second section discusses four guiding principles for programs that aim to reduce deficits in the quality of life and life chances of poor children. The third section describes promising intervention programs.

What does early antisocial behaviour predict? A follow-up of 4- and 5-year-olds from the Ontario Child Health Study.

OBJECTIVE: To examine the predictive accuracy of antisocial behaviours among 4- and 5-year-old children for problem behaviours 4 years later (ages 8 and 9 years). METHOD: Data from the Ontario Child Health Study (1983) and Follow-up (1987) are used. Predictive accuracy is conceptualized using positive predictive value (PPV) and sensitivity. The predictive accuracy of early antisocial behaviors for the 1987 outcomes is examined overall, by gender, by variable thresholds of predictor and outcome be gender, and by using contextual variables alone or in combination with antisocial behaviour recorded in 1983. Resulting: The predictive accuracy of 1983 antisocial behaviour for 1987 outcome is generally modest and differs by gender (better for boys for externalizing disorder [PPV = 41%, sensitivity = 57%]; better for girls for internalizing disorder [PPV = 13%, sensitivity = 80%]; better for boys for conduct problems [PPV = 54%, sensitivity = 21%]¿. Using either gender-specific thresholds or gender-neutral thresholds does not alter predictive accuracy in a consistent way, nor does the use of a single contextual variable. Use of a cumulative risk index increases PPV but decreases sensitivity. CONCLUSION: The predictive accuracy of antisocial behaviour in 4-and 5-years-old children over 4 years in a nonclinical community population is limited. The clinical, research, and policy implications of this work are discussed.

Single mothers in Ontario: sociodemographic, physical and mental health characteristics.

OBJECTIVE: To examine the sociodemographic, physical and mental health characteristics of single mothers in Ontario. DESIGN: Cross-sectional. SETTING: Ontario. PARTICIPANTS: Ontario residents aged 15 years or older who participated in the Ontario Health Supplement survey conducted between December 1990 and April 1991; of 9953 eligible participants, 1540 were mothers with at least 1 dependent child (less than 16 years of age). OUTCOME MEASURES: Prevalence rates of sociodemographic, physical and mental health characteristics. RESULTS: Single mothers were significantly more likely than the mothers in 2-parent families to be poor, to be 25 years of age or less, to have mental health problems (dissatisfaction with multiple aspects of life, affective disorder ever and 1 or more psychiatric disorders in the past year or ever) and to use mental health services. When compared by income level, poor single mothers had a higher prevalence of all mental health outcomes measured; the difference was significant for anxiety disorder in the past year or ever and for 1 or more psychiatric disorders in the past year or ever. In a logistic regression analysis, single-mother status was found to have the strongest independent effect on predicting mental health morbidity and utilization of mental health services; the next strongest was low income. CONCLUSIONS: Single mothers are more likely to be poor, to have an affective disorder and to use mental health services than mothers in 2-parent families. The risk of mental health problems is especially pronounced among poor single mothers. Further studies are needed to determine which aspects of single motherhood, apart from economic status, affect mental health outcomes.

What if we could eliminate child poverty? The theoretical effect on child psychosocial morbidity.

The aim of this study was to examine the attributable risk of low income for child psychosocial morbidity. Data on 1,996 6- to 16-year-old participants from the Ontario Child Health Study, a province-wide cross-sectional study done in 1983, were used. Out-comes measured included psychiatric disorders, poor school performance, chronic health problems, and social impairment. The attributable risk for low income and child psychosocial morbidity was generally small except among selected disorders in younger children. The implications of these findings are discussed.

Integrating assessment data from multiple informants.

OBJECTIVE: To examine the consequences for measurement of child psychiatric disorder (conduct and oppositional disorders) of not integrating the data on the same individual from different informants compared with integrating the information from parents and teachers, using three different strategies. METHOD: Data for the study came from problem checklist assessments done by parents and teachers of children aged 6 to 16 years (N = 1,134) selected with known probability from a general population sample and from structured interviews obtained in a stratified random subsample (n = 251). RESULTS: As expected, parent-teacher agreement was low. The pattern of associated features of disorder was found to vary markedly in parent-identified compared with teacher-identified disorder. Furthermore, combining informants had the disadvantage of masking the distinctive patterns of associated features noted in informant-specific disorders. Finally, by treating disorder as informant-specific, the internal properties of the measure are not generally inferior to those obtained by combining informants in various ways. CONCLUSION: Child psychiatric disorders should be conceptualized as informant-specific phenomena.

A single mothers' group for mothers of children attending an outpatient psychiatric clinic: preliminary results.

OBJECTIVES: To provide a preliminary report of data from 2 support groups for single mothers, all of whom were mothers of children attending a child outpatient psychiatric clinic. The groups' 2 purposes were: 1. to assess the feasibility of adding structured evaluation to a common clinical intervention; 2. to improve single mothers' parenting skills through raised levels of self-esteem, increased capacity for family functioning and reduced levels of depression. METHOD: Three structured evaluation instruments were used to measure the domains of self-esteem, family functioning and depression. These instruments were given to both groups of women on 3 occasions: 1. before the group; 2. after the group; 3. at a follow-up session 4 months after group termination. Open-ended questions were also asked at group termination. RESULTS: The questionnaire response rate was 100%; overall response rate for the 3 open-ended questions was 89%. Comparisons of pre-group and post-group scores showed that there was a significant increase in self-esteem (p < 0.01) and significant improvements in family functioning (p < 0.05) and depression (p < 0.01). CONCLUSION: It is possible to introduce a structured evaluation component into a common clinical intervention, and this support group seemed to assist single mothers' parenting skills. Methodologic concerns and future directions are discussed.

Relation between economic disadvantage and psychosocial morbidity in children.

OBJECTIVE: To examine the relation between low income and child psychosocial morbidity cross-sectionally and longitudinally. DESIGN: Cross-sectional survey with follow-up. SETTING: Ontario. PARTICIPANTS: Children aged 4 to 16 years from families selected by means of stratified, clustered and random sampling of 1981 Canada Census data. Results were based on the responses of 2503 children interviewed in 1983 and 1076 re-interviewed in 1987. OUTCOME MEASURES: Prevalence rates of psychiatric disorders, poor school performance and social impairment. RESULTS: There was a significant relation between low income and psychosocial morbidity, with a threshold at an income level of less than $10,000. Poor children 4 to 11 years of age were at greater risk of morbidity than poor children 12 to 16, but there were no significant age differences. Logistic regression revealed that low income and noneconomic factors (low maternal education and family dysfunction) shared significant independent influences on the prevalence of psychosocial morbidity. CONCLUSIONS: Low income is strongly associated with psychosocial morbidity in children. Both economic and noneconomic factors showed independent influences on morbidity. These findings have important clinical, scientific and policy implications.

Follow-up of psychiatric and educational morbidity among adopted children.

OBJECTIVE: The purpose of this study is to evaluate longitudinally the strength of association between adoptive status and psychiatric and educational morbidity and substance use. METHOD: This study makes use of data from the 1983 Ontario Child Health Study and 1987 follow-up. This community survey of children (4- to 16-years-old in 1983, 8- to 20-years-old in 1987) included a subpopulation of adopted children. The primary outcomes measured were psychiatric disorder, poor school performance, and substance use. RESULTS: Adoption, identified in 1983, in boys was a significant marker for psychiatric disorder in 1987. Adoption was not a significant risk indicator for educational morbidity or substance use in 1987. In the multivariate analyses, adoptive status demonstrated no independent influence on 1987 educational morbidity or substance use. However, adoptive status, in the presence of poor school performance in 1983, was a significant risk indicator for psychiatric disorder in 1987. CONCLUSIONS: Adopted children did not do significantly worse than nonadopted children over time in terms of educational morbidity or substance use, but adopted boys demonstrated a significantly increased risk of psychiatric disorder versus nonadopted boys.

Psychiatric disorders in adopted children: a profile from the Ontario Child Health Study.

Studies of clinical populations suggest that adopted children are overrepresented among children using mental health facilities, whereas studies using non clinical populations of adopted children have reached mixed conclusions about whether or not there is an increased psychological risk associated with adoption. Data from the Ontario Child Health Study, a community survey of children aged four to 16 years, which included a subpopulation of adopted children, were used to: 1. profile the characteristics of adoptive families; 2. examine the strength of adoptive status as a marker for psychiatric and educational morbidity; and 3. determine the extent to which adoptive status has an independent relationship with psychiatric and educational morbidities. The findings were: 1. adoptive mothers were significantly older than non adoptive mothers, but otherwise adoptive families did not differ significantly from non adoptive families, 2. adoption in boys, but not in girls, was a significant marker for psychiatric disorder and poor school performance; adoption in adolescent girls was a significant marker for substance use; and 3. multivariate analyses demonstrated no independent effect of adoption on psychiatric disorder or poor school performance; for adolescents, adoptive status did have an independent relationship with substance use for girls. The implications of these findings will be discussed.