Evaluation of an Assessment-based Intervention for Preschoolers and their Parents Final Outcomes Report Prepared by

Executive Summary Three unique programs designed to provide psychological assessments for preschool-aged children and their caregivers are offered by Preschool Diagnostic and Treatment Services (PDTS), through Psychiatry and Mental Health Services at Grand River Hospital. These programs are based on a clinician-caregiver collaborative model of intervention in which psychological assessment forms the basis for developing an understanding of the child's behaviour. The traditional model of psychological assessment views the clinician as the expert whose role it is to provide caregivers with assessment data and associated interpretations at the conclusion of the assessment. The current model, which utilizes a more collaborative approach to psychological assessment, involves caregivers throughout the assessment process so that their understanding of their children's challenges can evolve throughout the intervention. The programs offered by PDTS were developed to fill a distinct need in the community: assessment-based intervention for preschoolers and their caregivers when the presenting problem is clearly due to the child's challenges, as opposed to an active case of maltreatment, domestic violence, normal adjustment issues (e.g., divorce, birth of a new sibling, etc.) or other causes external to the child. In this assessment-based intervention, caregivers are involved and supported (not blamed) in the process of assessment and understanding of the child's challenges. Each of these three programs is designed to provide a continuum of assessment and consultation services depending on the needs of the preschoolers and their caregivers. Outpatient Assessment involves the child and his or her caregiver attending several sessions with a member of the psychology staff over a number of weeks. Preschool Assessment Placement involves the child attending a community preschool at Grand River Hospital for two to three mornings per week for several weeks with a resource teacher and member of the psychology staff. The third program is the Segregated Assessment Partnership Program (SAPP) which is a joint program with the Waterloo Region District School Board. Eight children in kindergarten are placed in SAPP for eight to nine weeks. Four resource teachers and a member of the psychology staff are involved, and consultation with speech/language therapists, occupational therapists and psychiatrist is also available. In this program evaluation, standardized measures of child behaviour (caregiver and teacher CBCL), parental stress (PSI) and management of child behaviour (MCBS) were obtained at pretest and post-intervention. Caregivers' and teachers' perception of knowledge gained through this assessment-based intervention was also assessed at post-intervention. Psychological assessment results indicated that the main challenges of the preschoolers involved a diagnosable disorder (e.g., several children were diagnosed with PDD), or a risk for developing certain challenges (e.g., monitor for ADHD, or Learning Disorder). Results revealed clinically important differences from pre-to post-intervention on standardized measures of child behaviour and parental stress. At post-intervention, teachers reported less problematic child behaviour (t=2.78, p=0.013) and parents reported less stress (trend toward significance; t=1.53, p=0.140). Caregivers and teachers were also quite satisfied with the knowledge they gained by participating in these programs. This evaluation begins to shed light on the benefits of assessment-based intervention for preschoolers with inherent emotional, behavioural or developmental challenges. It is hoped that intervention with preschoolers will facilitate an optimal developmental trajectory. 2 Project Summary The purpose of the evaluation was to assess three programs for preschool children and their caregivers offered through Preschool Diagnostic and Treatment Services (PDTS) at Grand River Hospital's Psychiatry and Mental Health Services. These programs were designed to meet the unique needs of preschoolers with emotional, behavioural or developmental problems that appear to arise from the genetic or neurobiological contributions of the child; that is, the problems do not appear to be due to active problems external to the child such as child maltreatment or domestic violence. The intervention delivered within these programs is assessment-based, utilizing a clinician-caregiver collaborative assessment model in which the goal is to help caregivers and teachers participate in developing a better understanding of the children's behaviour. The questions asked in this program evaluation were: (1) Do caregivers think they better understand their children after their involvement in one of the three assessment-based programs? (2) Will caregivers' and teachers' perceptions of the children's behaviour (as reported with the Child Behaviour Checklist) change (or improve) after the children undergo assessment-based intervention? (3) Will caregiver involvement in the program reduce their perceived stress (as measured by a standardized self-report scale)? (4) Will caregivers' management of their children's behaviour change after their involvement in this intervention? The target population for these programs is children aged 2.5 to 5 years with emotional, behavioural or developmental challenges that appear to have an inherent or neurobiological basis. The caregivers of this collaborative intervention are involved in the assessment and development of understanding of the children. The relevant stakeholders for this evaluation project include clients of the program (both current and future, and their families), mental health clinicians, teachers of preschoolers in public and private elementary schools, teachers in daycare settings, school boards, community partners (e.g., KidsLink, KidsAbility), Waterloo Region Children's Mental Health Planning and Advisory Committee, Preschool Speech/Language Advisory Committee of the Waterloo Region, Ministry of Child and Youth Services, and Grand River Hospital Board of Directors and Senior Management team. Introduction The preschool years can have a significant impact on an individual's developmental, psychosocial and educational outcomes. There is credible evidence 3 From the perspective of early identification and intervention, it is important to have an understanding of both normative and atypical development. It may be difficult to distinguish between normative kinds of behaviour for preschoolers, such as tantrums and non-compliance, and early indicators of problematic behaviour (Keenan & Wakschhlad, 2000). As toddlers develop more cognitive, language and regulation skills, they can better mange developmental challenges The understanding of the development of problematic behaviours appears to be improving, resulting in earlier identification of problematic behaviours currently than in the past. While many children are not identified until their elementary school years, early identification of emergent mental health issues is now possible for children as young as two years of age With regard to the prevalence of emergent mental health challenges in children, it has been estimated that at least 20% of children experience some form of mental health disorder 4 The most common mental health disorders children experience are anxiety, behavioural, and depressive disorders Numerous factors are associated with emotional and behavioural problems in preschool children. In a follow up study of children from preschool-age to adolescence, it was found that although parental traits predicted adolescent status, child-centred skills at ages 4-7 years were better predictors than were parental traits The relationships between parental stress, parental practices and child behaviour are also of interest. While positive parenting practices have been linked to prosocial skills in children (Koblinsky et al., 2006); some researchers have focussed on less optimal parenting practices. Less positive parenting practices with respect to nurturing and discipline appear to be linked to child behavioural problems. For example, maternal low self-efficacy In addition to personal and environmental factors associated with mental health problems, the interplay between genetics and the environment is also intriguing. The understanding of the genetic contributions to childhood mental health disorders is growing rapidly (e.g., Developmental psychopathology concerns the pathways associated with the onset of mental health disorders. Numerous risk factors for mental health issues have been identified, including adverse early experiences, parental mental illness, family dysfunction, stress including stressful events and chronic stress, chronic medical illness, poverty, learning disorders and residential instability Similarly, the disorders themselves may also be described as following particular pathways. That is, disorders can progress to a wide range of possible outcomes. Multifinality is a term used to describe the diverse outcomes produced by disorders There is a substantial body of research on the effectiveness of prevention and intervention programs with children (for example, see Barker, 2002). Likewise, some effectiveness studies of preventive strategies with preschool-aged children (for example see 7 Method Three service delivery models within the Preschool Diagnostic and Treatment Services Programs were evaluated. Preschool Diagnostic and Treatment Services is an early intervention program that focusses on assisting children 2 1/2 to 5 years of age. It is under the umbrella of Psychiatry and Mental Health Services at Grand River Hospital, Kitchener, Ontario. The overarching goal of Preschool Diagnostic and Treatment Services is to increase caregiver and teacher understanding of the child, primarily through the process of psychological assessment with support from the multidisciplinary team. Children are eligible if they display moderate to severe behavioural, social, emotional or developmental challenges at home and/or at school, preschool, or daycare. Triage occurs by telephone. When it is determined during triage that there may be an inherent basis for the difficulties the child is experiencing, the case will be eligible for the process of intake. Cases where the presenting problem appears to be due to caregiver problems, or other problematic interpersonal or environmental problems are referred to another, more appropriate agency. At intake, caregivers meet with a clinician separately and are asked to thoroughly describe the child's problem while the child participates in cognitive, behavioural and speech/language screening. Caregivers are provided feedback from this initial appointment, and are given recommendations. If they are accepted for further assessment, then options for service are described (see below for details). Caregivers are provided with information (e.g., pamphlets on stress in children) to help them cope and caregivers know they can contact the clinician if need be. There are three options for further service from Preschool Diagnostic and Treatment Services: 1. Outpatient Assessment (OA) involves the child and caregivers attending several sessions with a member of the psychology staff over a number of weeks. The goal of outpatient assessment is to understand the child's cognitive, behavioural, and socio-emotional development through seeing the child and/or parent once per week for several weeks. The length of the assessment is dictated by the needs of the child and family.An observation within a structured setting in which the child is enrolled (if appropriate) also informs this process. Preschool Assessment Placement (AP) involves the child attending Grand River Hospital Preschool (an integrated, community preschool) for several weeks, two or three mornings per week. During that time, assessment and/or consultation takes place. There is involvement with a resource teacher and member of the psychology staff. The goal of placement into a Preschool group setting is to assess children with limited or no experience in a structured setting with peers, thereby enabling a comprehensive assessment of variables such as social development, and adaptability. In some situations, it also encourages caregivers to take the first important step toward separation from their 'special needs' child within a supportive, clinical setting. The Segregated Assessment Partnership Program (SAPP) is a joint program between Preschool Diagnostic and Treatment Services and the Waterloo Region District School Board. Children who attend a school within that school board may be placed in the SAPP program for eight to nine weeks, four afternoons per week, for psychological assessment and consultation purposes. There are eight children and four resource teachers dedicated to classroom support and re-integration of the children back into their home school with a comprehensive plan of care. Speech/language and occupational therapy assessments are also available, as is consultation with 8 psychiatry. The goal of placement is to encourage an understanding of the child and to strategize how that information can assist the school system to develop the best behavioural and learning strategies possible for that child within their system. The decision regarding which program to place the child into is dependent on the child's current setting, presenting challenges, case complexity, and goals of assessment. The assessment-based intervention used within all three programs utilizes a collaborative approach to psychological assessment, involving caregivers throughout the assessment process so that their understanding of their children's challenges can evolve throughout the intervention. This may differ from the traditional model of psychological assessment in which the clinician conducts testing with the child (e.g., see With regard to the process of psychological assessment, the following procedures are common to all three programs offered by PDTS: caregiver interview; teacher interview (when the child is involved in another structured setting); standardized testing of the child (which might include cognitive, memory, language, visual-spatial, and academic testing); completion of standardized rating scales of the child's socio-emotional, behavioural, adaptive, and executive functioning by caregivers and teachers; and observation of the child (during testing and in another structured setting if available; possibly at home as necessary). During the testing phase of the assessment, ongoing feedback is provided to caregivers regarding testing results, clinical observations, and preliminary formulations of the child's difficulties. Distinct within the SAPP and Preschoolbased assessment programs, caregivers and teachers also participate in a "guided observation" of the child. This entails the clinician accompanying the caregiver or teacher behind a one-way mirror for the purpose of describing strengths and weakness, progress, strategies being implemented, and observations that are important in developing the formulation. Common to all programs, at the completion of the assessment phase, the clinician(s) involved with the child meet with caregivers for a final interpretive feedback in which the results of the assessment (including diagnosis if applicable) are provided. The main thrust of this feedback is to provide a solid formulation of the child's challenges and strengths, and recommendations stemming from that formulation. Caregivers are also given a written report that details the assessment results, formulation, and recommendations. With caregiver consent, the clinician(s) also attend a feedback meeting with the child's school (or daycare) to explain the formulation and discuss recommendations. Reports are distributed to other agencies as requested by the caregivers. Through a pre-post evaluation model, caregiver and teacher responses to the children's difficulties were assessed. Given that the service is assessment-based in that the primary purpose is to seek understanding of (versus provide treatment for) the child, one outcome examined was the level of understanding of the child generated by each service delivery model described above. Related to an increased understanding of the child, changes in parental stress, the ability to manage challenging behaviour, and perceptions of the child's behaviour as pathological were also evaluated. 9 Procedure The caregivers and teachers of all preschool children referred to and receiving these services between January 2007 and March 2007 were invited to participate. A research assistant who was not involved in the delivery of services obtained informed consent, and distributed and collected the questionnaires at pre-test from caregivers and teachers. Due to the timing of the funding for this program evaluation, pre-test data were collected after intake; that is, after caregivers had already been given information about their child and about issues their child may be experiencing (e.g., stress), but prior to their involvement in the more comprehensive assessment programs. At the end of the programs (post-test), questionnaires were distributed at the final caregiver or teacher meeting, along with an addressed, stamped envelope for returning the questionnaire. The research assistant contacted participants by telephone to remind them to return the questionnaires one week following distribution, and collected two directly from participants who had difficulty mailing them. Measures consisted of standardized scales of child and parental behaviour and parental stress that were collected at pre-test (T1) and at the conclusion of program services (post-intervention; T2). The Parent and Teacher versions of the Child Behavior Checklist (CBCL; Data Analysis Demographic and pre-test data were analysed with descriptive statistics. The main purpose was to examine change in symptoms and understanding, therefore the main analysis was a paired ttest (pre-to post-intervention). Pearson Correlation was used to identify relationships between variables. Results Nineteen children were enrolled in all three programs during the evaluation period (Outpatient n=8, SAPP n=7, and Preschool Assessment Placement n=4). Reports for eighteen of the children were provided by parents and one was provided by grandparents. Reports for eighteen children were provided by teachers. One child did not have a teacher. Most caregivers (89.47%) reported being in a coupled relationship (See The mean age of the children was 4.6 years (SD 0.51), with a greater presentation of boys (n=13) than girls (n=6). Five children were reported by caregivers as having a previously identified disability; while 6 children were reported by teachers as having a previously identified disability. There was only one reported disability (cleft palate) for one child that was reported by both the parent and teacher; that is, there was no other congruence between parent and teacher reports of disability at baseline. Combined, caregivers and teachers reported an illness or physical disability, such as, cleft lip/palate, hearing loss, allergies and asthma. Three children were reported to have some previously identified developmental challenges namely cognitive, language and speech delays, and one child was reported to have a previously identified learning challenge. In terms of their clinical assessment, this diverse sample appears to resemble a typical cohort of participants in the Preschool Diagnostic and Treatment Services. The psychological assessments conducted during the evaluation period revealed the following diagnoses/formulations: Pervasive Developmental Disorder (n= 3 possibly 4), Learning Disability (n=2), Reactive Attachment Disorder (n=2), Attention-Deficit/Hyperactivity Disorder (n=3), Receptive-Expressive Language Disorder (n=1), and many challenges such as underdeveloped social and emotional regulation skill (n=4), speech/language issues (n=2), lower cognitive functioning, impaired memory functioning, and complex gross and fine motor concerns. At least 16 of the 19 children exhibited a clearly identifiable diagnosis or challenge, and several will continue to be monitored for ADHD, LD, mood challenges, anxiety challenges and language issues. There were 17 teachers and one daycare worker (referred to hereafter as a teacher) who reported years of experience as a mean of 14 years (SD 11.30; range 0.3 to 40 years; median = 12 years), and class sizes of an average of 19.39 (SD 1.38) children. Teachers indicated that they knew the children for an average of 6.52 months (SD 4.39). Eleven teachers (61%) indicated that they knew the child moderately well, while seven (39%) knew the child very well. Children spend an average of 12.5 hours (SD 5.57) at the school / daycare. In terms of caregiver completion of the CBCL at T1, the mean scores on the emotionally reactive and withdrawn subscales were in the borderline range, and the means of all other subscales were below this range. However, several individual children were in the borderline range and a few were in the clinical range With respect to the parental stress scores, seven of the 19 caregivers (37%) would be considered to have clinically significant levels of stress using both raw scores and an adjustment for missing values (Abidin, 1983), and the overall mean score (85.84; SD 27.99) falls below this clinical cut off. Only one caregiver scored higher than 24 on the Defensive Responding (DR) subscale; however, for this sample, the low scores on DR are likely because the caregiver

A randomised controlled trial to assess the effectiveness of a single session of nurse administered massage for short term relief of chronic non-malignant pain

Background: Massage is increasingly used to manage chronic pain but its benefit has not been clearly established. The aim of the study is to determine the effectiveness of a single session of nurse-administered massage for the short term relief of chronic non-malignant pain and anxiety. Methods: A randomised controlled trial design was used, in which the patients were assigned to a massage or control group. The massage group received a 15 minute manual massage and the control group a 15 minute visit to talk about their pain. Adult patients attending a pain relief unit with a diagnosis of chronic pain whose pain was described as moderate or severe were eligible for the study. An observer blind to the patients' treatment group carried out assessments immediately before (baseline), after treatment and 1, 2, 3 and 4 hours later. Pain was assessed using 100 mm visual analogue scale and the McGill Pain Questionnaire. Pain Relief was assessed using a five point verbal rating scale. Anxiety was assessed with the Spielberger short form State-Trait Anxiety Inventory. Results: 101 patients were randomised and evaluated, 50 in the massage and 51 in the control group. There were no statistically significant differences between the groups at baseline interview. Patients in the massage but not the control group had significantly less pain compared to baseline immediately after and one hour post treatment. 95% confidence interval for the difference in mean pain reduction at one hour post treatment between the massage and control groups is 5.47 mm to 24.70 mm. Patients in the massage but not the control group had a statistically significant reduction in anxiety compared to baseline immediately after and at 1 hour post treatment. Conclusion: Massage is effective in the short term for chronic pain of moderate to severe intensity

Effectiveness evaluation of an integrated automatic termomechanic massage system (SMATH® system) in non-specific sub-acute and chronic low back pain - a randomized double-blinded controlled trial, comparing SMATH therapy versus sham therapy: study protocol for a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Low back pain (LBP) is a major health problem in modern society, with 70-85% of the population experiencing LBP at some time in their lives. Each year, 5-10% of the workforce misses work due to LBP, most for less than 7 days. Almost 10% of all patients are at risk of developing chronic pain and disability. Little clinical evidence is available for the majority of treatments used in LBP therapy. However, moderate evidence exists for interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation, and cognitive behavioral therapy for subacute and chronic LBP. The SMATH^®system (system for automatic thermomechanic massage in health) is a new medical device (MD) that combines basic principles of mechanical massage, thermotherapy, acupressure, infrared therapy, and moxibustion. SMATH^®is suitable for automatic multidisciplinary treatment on patients with non-specific sub-acute and chronic LBP.</p> <p>Methods/design</p> <p>This paper describes the protocol for a double-blinded, sham-controlled, randomized, single-center short term clinical trial in patients with non-specific sub-acute and chronic LBP aged 18 to 70 years. The primary outcome will be the effectiveness of SMATH^®versus sham therapy (medical device without active principles) determined by evaluating self perceived physical function with Roland Morris Disability Questionnaire (RMDQ) scores after 4 weeks of treatment (end of treatment). Major secondary outcome will be effectiveness of SMATH^®determined by evaluating self perceived physical function comparing RMDQ scores between end of treatment and baseline. The trial part of the study will take 7 months while observational follow-up will take 11 months. The sample size will be 72 participants (36 for each arm). The project has been approved by the Ethical Committee of Cremona Hospital, Italy on 29 November 2010.</p> <p>Discussion</p> <p>Compared to other medical specialties, physical and rehabilitation medicine (PRM) has not yet received the deserved recognition from clinicians and researchers in the scientific community, especially for medical devices. The best way to change this disadvantage is through well-conducted clinical research in sham-controlled randomized trials. Sham treatment groups are essential for improving the level of evidence-based practice in PRM. The present trial will counter the general lack of evidence concerning medical devices used in LBP therapy.</p> <p>Trial Registration</p> <p>ISRCTN: <a href="http://www.controlled-trials.com/ISRCTN08714168">ISRCTN08714168</a></p

Effectiveness of focused structural massage and relaxation massage for chronic low back pain: protocol for a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Chronic back pain is a major public health problem and the primary reason patients seek massage treatment. Despite the growing use of massage for chronic low back pain, there have been few studies of its effectiveness. This trial will be the first evaluation of the effectiveness of relaxation massage for chronic back pain and the first large trial of a focused structural form of massage for this condition.</p> <p>Methods and Design</p> <p>A total of 399 participants (133 in each of three arms) between the ages of 20 and 65 years of age who have low back pain lasting at least 3 months will be recruited from an integrated health care delivery system. They will be randomized to one of two types of massage ("focused structural massage" or "relaxation massage"), or continued usual medical care. Ten massage treatments will be provided over 10 weeks. The primary outcomes, standard measures of dysfunction and bothersomeness of low back pain, will be assessed at baseline and after 10, 26, and 52 weeks by telephone interviewers masked to treatment assignment. General health status, satisfaction with back care, days of back-related disability, perceived stress, and use and costs of healthcare services for back pain will also be measured. Outcomes across assigned treatment groups will be compared using generalized estimating equations, accounting for participant correlation and adjusted for baseline value, age, and sex. For both primary outcome measures, this trial will have at least 85% power to detect the presence of a minimal clinically significant difference among the three treatment groups and 91% power for pairwise comparisons. Secondary analyses will compare the proportions of participants in each group that improve by a clinically meaningful amount.</p> <p>Conclusion</p> <p>Results of this trial will help clarify the value of two types of massage therapy for chronic low back pain.</p> <p>Trial registration</p> <p>Clinical Trials.gov NCT 00371384.</p

Unmet psychosocial needs in haematological cancer: A systematic review

The final publication is available at Springer via http://dx.doi.org/10.1007/s00520-014-2123-5A systematic review of key online databases and psycho-oncology journals was conducted to identify papers that formally assessed unmet psychosocial needs in adults with a diagnosis of haematological cancer

Massage Therapy for Osteoarthritis of the Knee: A Randomized Dose-Finding Trial

In a previous trial of massage for osteoarthritis (OA) of the knee, we demonstrated feasibility, safety and possible efficacy, with benefits that persisted at least 8 weeks beyond treatment termination.We performed a RCT to identify the optimal dose of massage within an 8-week treatment regimen and to further examine durability of response. Participants were 125 adults with OA of the knee, randomized to one of four 8-week regimens of a standardized Swedish massage regimen (30 or 60 min weekly or biweekly) or to a Usual Care control. Outcomes included the Western Ontario and McMaster Universities Arthritis Index (WOMAC), visual analog pain scale, range of motion, and time to walk 50 feet, assessed at baseline, 8-, 16-, and 24-weeks.WOMAC Global scores improved significantly (24.0 points, 95% CI ranged from 15.3-32.7) in the 60-minute massage groups compared to Usual Care (6.3 points, 95% CI 0.1-12.8) at the primary endpoint of 8-weeks. WOMAC subscales of pain and functionality, as well as the visual analog pain scale also demonstrated significant improvements in the 60-minute doses compared to usual care. No significant differences were seen in range of motion at 8-weeks, and no significant effects were seen in any outcome measure at 24-weeks compared to usual care. A dose-response curve based on WOMAC Global scores shows increasing effect with greater total time of massage, but with a plateau at the 60-minute/week dose.Given the superior convenience of a once-weekly protocol, cost savings, and consistency with a typical real-world massage protocol, the 60-minute once weekly dose was determined to be optimal, establishing a standard for future trials.ClinicalTrials.gov NCT00970008