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Systematic reviews and meta-analyses suggest that behaviour change interventions have modest effect sizes, struggle to demonstrate effect in the long term and that there is high heterogeneity between studies. Such interventions take huge effort to design and run for relatively small returns in terms of changes to behaviour.
So why do behaviour change interventions not work and how can we make them more effective? This article offers some ideas about what may underpin the failure of behaviour change interventions. We propose three main reasons that may explain why our current methods of conducting behaviour change interventions struggle to achieve the changes we expect: 1) our current model for testing the efficacy or effectiveness of interventions tends to a mean effect size. This ignores individual differences in response to interventions; 2) our interventions tend to assume that everyone values health in the way we do as health professionals; and 3) the great majority of our interventions focus on addressing cognitions as mechanisms of change. We appeal to people’s logic and rationality rather than recognising that much of what we do and how we behave, including our health behaviours, is governed as much by how we feel and how engaged we are emotionally as it is with what we plan and intend to do.
Drawing on our team’s experience of developing multiple interventions to promote and support health behaviour change with a variety of populations in different global contexts, this article explores strategies with potential to address these issues.
Differential susceptibility theory (DST) posits that individuals differ in their developmental plasticity: some children are highly responsive to both environmental adversity and support, while others are less affected. According to this theory, “plasticity” genes that confer risk for psychopathology in adverse environments may promote superior functioning in supportive environments. We tested DST using a broad measure of child genetic liability (based on birth parent psychopathology), adoptive home environmental variables (e.g., marital warmth, parenting stress, and internalizing symptoms), and measures of child externalizing problems (n = 337) and social competence (n = 330) in 54-month-old adopted children from the Early Growth and Development Study. This adoption design is useful for examining DST because children are placed at birth or shortly thereafter with nongenetically related adoptive parents, naturally disentangling heritable and postnatal environmental effects. We conducted a series of multivariable regression analyses that included Gene × Environment interaction terms and found little evidence of DST; rather, interactions varied depending on the environmental factor of interest, in both significance and shape. Our mixed findings suggest further investigation of DST is warranted before tailoring screening and intervention recommendations to children based on their genetic liability or “sensitivity.”
Increasing attention is paid to importance of hyperprolactinaemia. Sexual dysfunction and osteoporosis are reported in such patients. There is little naturalistic data showing prevalence and severity of hyperprolactinaemia in asymptomatic patients receiving antipsychotics.
All outpatients in a community mental health team in Halifax receiving antipsychotics with diagnosis of schizophrenia or bipolar disorder had prolactin measurements. Upper Limit of Normal (ULN) prolactin 500mIU/L (males) and 700mIU/L (females).
Prolactin levels were obtained in 226 patients providing 253 incident cases as antipsychotic changes were made over 36-month period.
Abnormal values were found in 49% females and 29% males - 39% of the cohort. Levels >1000 mIU/L were seen in 23% (females 36%, males 10%). From the 61/125 females with abnormal levels, 74% of these had levels >1000 mIU/L and 16/125 (13%) >2000 mIU/L. Only 13/128 males had levels >1000 mIU/L. Prevalence of hyperprolactinaemia in those on antipsychotic monotherapy: olanzapine 7%, typicals 33%, amisulpride 92%, Clozapine 4%, risperidone oral 83%, and risperidone consta 65%. In Risperidone Consta patients, 15/23 (65%) had hyperprolactinaemia including 100% of females (10/10). Most females on oral risperidone (12/13) also had hyperprolactinaemia and had values >1000 mIU/L in11/12.
Routine prolactin screening showed abnormal values in 39% and significantly abnormal levels (>1000 mIU/L) that could lead to drug/dosage alterations in 23%. Exceptionally high levels >2000 mIU/L were found in 7%. Females on oral and consta risperidone may be particularly at risk of the effects of hyperprolactinaemia.
A large, observational, multinational cross-sectional pharmacoepidemiological study was performed to determine the prevalence of diabetes and other metabolic disorders in patients with schizophrenia receiving atypical antipsychotic drugs in Europe.
The study included adult outpatients with schizophrenia (DSM-IV-TR) treated for at least three months by an antipsychotic drug. Patients treated with classical or atypical antipsychotic drugs were recruited into two parallel strata (ratio of 1:3). A fasting blood sample was taken and height, weight, waist and hip circumference and blood pressure measured during a single visit. Biochemical parameters assessed included glucose, insulin, HbA1c, triglycerides, total cholesterol, HDL-cholesterol and apolipoprotein B.
2463 patients (median age: 41.0 years; 54.6% male) were included in twelve countries. among these, 10.9% of patients were treated for hypertension, 7.1% for a lipid disorder, 0.3% for type I diabetes and 3.5% for type II diabetes. in addition, 26% of untreated patients had dysglycaemia, 67.7% dyslipidemia and 38% had hypertension. 34% of the patients presented a metabolic syndrome. No overall difference was observed in the proportion of patients with glycaemic and lipid disorders between the two treatment strata. Values for weight-related variables were slightly higher in the atypical stratum, whereas hypertension was more frequent in the classical stratum (47.3%) than in the atypical stratum (42.2%).
The results of this study emphasise the need for careful follow-up of patients with schizophrenia treated with antipsychotic drugs to detect the occurrence of metabolic disorders. the proportion of patients with glycaemic or lipid disorders was very high and largely underdiagnosed.
As awareness of ADHD has increased throughout the world, interest has grown beyond the constellation of ADHD symptoms, including long-term effects and impact on people's lives.
To examine the consequences of childhood ADHD and the relevance of these outcomes in different world regions.
This analysis examined the publication trends of studies of long-term outcomes of ADHD over time and among world regions.
Study identification followed Cochrane guidelines. Twelve databases were searched for reports published in English 1980–2010. Limiting criteria were designed to maximize study inclusion while maintaining a high level of study rigor: the studies were to
(1) be peer-reviewed,
(2) be primary study reports,
(3) include a comparator group or baseline, and
(4) report outcome results measured for a mean of 8 years (prospective studies, range of all studies was 6 months-40 years) after the start of the study, in late adolescence, or adulthood.
The fully-defined electronic search yielded 4615 citations, which were then reviewed manually based on the titles and abstracts, yielding a final of 371 studies.
Study publication trends analysed included: publication year, country and world region of origin, outcome types, and study types. In general, the numbers of studies published per year globally has increased substantially (from 2 in 1980 to more than 40/year in 2007 and 2008) with differences observed between Europe and North America.
Analysis of publication trends can provide insight into outcomes of ADHD and the focus of specific world regions.
As awareness of ADHD has increased worldwide, interest has grown beyond the constellation of ADHD symptoms, to include long-term impact on people's lives and society in general.
Examine the results of studies of long-term life consequences of ADHD.
To identify areas of life affected long-term by ADHD and differences in outcomes with and without ADHD treatment.
Following Cochrane guidelines, 12 databases were searched for studies published in English (1980–2010). Limiting criteria maximized study inclusion while maintaining high study rigor: (1) peer-reviewed, (2) primary study reports, (3) including a comparator condition, and (4) reporting long-term outcomes (mean 8 years, range 6 months-40 years from study start for prospective studies; subjects in adolescence or adulthood for retrospective or cross-sectional studies). The fully-defined electronic search yielded 4615 citations. Manual review based on titles and abstracts yielded 340 studies included in this analysis of outcomes.
The majority of studies (86%, 243 of 281; studies of untreated ADHD only) showed that untreated ADHD has substantial negative long-term outcomes, encompassing nine broad-ranging areas of life: non-medicinal drug use/addictive behaviour, antisocial behaviour, academic achievement, occupational achievement, public services use, self-esteem, social function, obesity, and driving outcomes. In contrast, most studies including ADHD pharmacotherapy and/or non-pharmacotherapy (94%, 46 of 49) showed that compared with baseline or untreated ADHD, long-term outcomes improved or stabilized with treatment of ADHD.
ADHD has notable negative long-term consequences, and this negative impact may be reduced with treatment of ADHD. Supported by Shire Development Inc.
Neuroimaging studies of attention-deficit/hyperactivity disorder (ADHD) have revealed structural deviations of the corpus callosum in children and adolescents. However, little is known about the link between callosal morphology and symptoms of inattention or hyperactivity in adulthood, especially later in life.
We aimed to further expand this understudied field by analyzing a large population-based sample of 280 adults (150 males, 130 females) in their late sixties and early seventies.
We applied a well-validated approach capturing the thickness of the corpus callosum with a high regional specificity at 100 equidistant points. In addition to correlating point-wise callosal thickness with ADHD symptom measures within the whole sample, we tested for sex interactions.
There were significant sex interactions with respect to measures of inattention and hyperactivity, with follow-up analyses revealing significant negative correlations in males (see Fig. 1 – Top). In contrast, there were positive correlations with respect to hyperactivity only in females (see Fig. 1 – Bottom).
A thinner corpus callosum may be associated with fewer fibers or less myelination. Thus, the negative correlations, as observed in males, suggest an impaired inter-hemispheric communication necessary to sustain motor control and attention, which may contribute to symptoms of hyperactivity, impulsivity and/or inattention. The functional relevance and underlying mechanisms of the positive correlations, as detected in females, remain to be resolved.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
This study examined the long-term effects of a randomized controlled trial of the Family Check-Up (FCU) intervention initiated at age 2 on inhibitory control in middle childhood and adolescent internalizing and externalizing problems. We hypothesized that the FCU would promote higher inhibitory control in middle childhood relative to the control group, which in turn would be associated with lower internalizing and externalizing symptomology at age 14. Participants were 731 families, with half (n = 367) of the families assigned to the FCU intervention. Using an intent-to-treat design, results indicate that the FCU intervention was indirectly associated with both lower internalizing and externalizing symptoms at age 14 via its effect on increased inhibitory control in middle childhood (i.e., ages 8.5–10.5). Findings highlight the potential for interventions initiated in toddlerhood to have long-term impacts on self-regulation processes, which can further reduce the risk for behavioral and emotional difficulties in adolescence.
Attention deficit hyperactivity disorder (ADHD) is highly heritable and is associated with lower educational attainment. ADHD is linked to family adversity, including hostile parenting. Questions remain regarding the role of genetic and environmental factors underlying processes through which ADHD symptoms develop and influence academic attainment.
This study employed a parent-offspring adoption design (N = 345) to examine the interplay between genetic susceptibility to child attention problems (birth mother ADHD symptoms) and adoptive parent (mother and father) hostility on child lower academic outcomes, via child ADHD symptoms. Questionnaires assessed birth mother ADHD symptoms, adoptive parent (mother and father) hostility to child, early child impulsivity/activation, and child ADHD symptoms. The Woodcock–Johnson test was used to examine child reading and math aptitude.
Building on a previous study (Harold et al., 2013, Journal of Child Psychology and Psychiatry, 54(10), 1038–1046), heritable influences were found: birth mother ADHD symptoms predicted child impulsivity/activation. In turn, child impulsivity/activation (4.5 years) evoked maternal and paternal hostility, which was associated with children's ADHD continuity (6 years). Both maternal and paternal hostility (4.5 years) contributed to impairments in math but not reading (7 years), via impacts on ADHD symptoms (6 years).
Findings highlight the importance of early child behavior dysregulation evoking parent hostility in both mothers and fathers, with maternal and paternal hostility contributing to the continuation of ADHD symptoms and lower levels of later math ability. Early interventions may be important for the promotion of child math skills in those with ADHD symptoms, especially where children have high levels of early behavior dysregulation.
Decades of research have highlighted the significance of parenting in children's development, yet few studies have focused specifically on the development of parental monitoring strategies in diverse families living in at-risk neighborhoods. The current study investigated the development of active (i.e., parental discussions and curfew rules) and passive (i.e., child communication with parents) parental monitoring strategies across different developmental periods (middle childhood and adolescence; Grades 4–5 and 7–11) as well as individual (child, parent), family, and contextual antecedents (measured in kindergarten) of this parenting behavior. Using an ecological approach, this study evaluated longitudinal data from 753 participants in the Fast Track Project, a multisite study directed at the development and prevention of conduct problems in at-risk children. Latent trajectory modeling results identified little to no mean growth in these monitoring strategies over time, suggesting that families living in at-risk environments may engage in consistent levels of monitoring strategies to ensure children's safety and well-being. Findings also identified several kindergarten antecedents of the growth factors of these parental monitoring strategies including (a) early child conduct problems; (b) parental warmth/involvement, satisfaction, and efficacy; and (c) parent–child relationship quality. These predictive effects largely highlighted the important role of early parenting behaviors on later levels of and growth in parental monitoring strategies. These findings have important implications for potential prevention and intervention targets to promote the development of parental monitoring strategies among families living in more at-risk contexts.
Chapter 6 examines how later stories about artistic competition, related by al-Maqrizi, Mustafa ‘Ali, and Qadi Ahmad, consider painting in the context of deceptive rhetoric in pursuit of truth, as advocated in Plato’s Phaedrus. The chapter concludes by comparing this understanding of painting with that rooted in a similar story, the competition of Zeuxis and Parrhasius. Adopted from antiquity by German Enlightenment thinkers as the paradigm for representation and the disinterested observer, this story establishes paradigms of artistry and mimesis in the Western tradition that cannot account for opposite premises established in Islamic discourses. The comparison between the two narratives underscores the antique tradition as part of a shared Islamic and European heritage diverging through distinct histories of interpretation. Comparison with European theorization of the image uncovers the bias inherent to normative art-historical premises about the social and psychological functions of the image that obscure alternative modes of perception, whether in cultures whose alterity is determined by being in the past or by being elsewhere. The story of the competition of the artists outlines an alternative paradigm, rooted in spiritually trained subjectivity rooted in the heart and resisting the rationalist exteriority of representation presumed in dominant modern models.
In contrast to the transcendent image eliding idolatry through immateriality or dematerialization, the transgressive image courts sin to transcend the self. Through the Abrahamic story of the prophet Joseph and Zuleikha, transformed from Judaic and Islamic exegesis to poetry and painting, Chapter 8 explores the trope of the transgressive image. Development of the story from the Talmud into the Bible and subsequent interplay between Jewish and Islamic commentaries suggests close interreligious communication. The story’s fifteenth-century romantic popularization in Persian poetry, first by Sa’di and then by Jami, used tropes of dreams and idols to transform the story into a parable describing the path to divine union. Combining text with image, Bihzad’s famous rendition of the climactic scene responds to the poem’s intermediality. Comparison with the transgressive dream vision central to the tale of Shaykh Sam’an in Attar’s Language of the Birds underscores a broader recognition of idolatrous transgression as a path to salvation. The chapter concludes by contrasting the mystical, humanizing interpretation embodied in these tales with depictions of the same romance in Europe. Recognizing the independence of European painting from text as an inappropriate paradigm for manuscript paintings embedded in texts, the chapter suggests the need for contextual critical reading of poetry through theology as well as politics to ascribe visual meaning.
Far from a mere technique of three-dimensional spatial representation, perspective has become a dominant metaphor for objectivity, rationalism, mastery, and domination. Conversely, to lack perspective, as in Islamic art, suggests an absence or ineptitude in these qualities often Chapter 10 examines the roots of European perspectivalism from the Italian Renaissance in its relationship with knowledge from Islamic discourses; interaction with European religious doctrines; and the rise and normalization of colonialism. It argues that, far from presaging a modern, secular, and supposedly objective way of looking, discussions of perspective in the seventeenth century were deeply engaged with proofs of the existence of God. This limited the potential of multi-perspectivalism to enable
Chapter 4 examines how the Quran informs perception outside of the parameters of art. It traces an ontology of perception rooted in the heart emerging from a hierarchy of the senses implicit in Quranic passages. It contrasts the complex ontology of the Quran as representation of the divine tablet as simultaneously writing and sound, always complete and always immanent, with secular interpretations of its material history. The Quran emerges less as a book than as a sonic image of the divine continually present in all its parts. The second part of the chapter examines how internalized perception of the Quran gave way to extensive discourses of love, the composite senses, and the metaphor of the heart-as-mirror as central to sensory and imaginary experience. The emotive response to Quranic beauty reverberates with discourses of the heart, the imaginary, and the contemplative faculties in Islamic thought. The discussion suggests that the aesthetics of the Quran reflected and promoted existing norms of inward mimesis. Drawing out connections with Greek and Buddhist philosophy inherited through Sasanian and Abbasid policies of translation, the chapter belies later European appropriations of antiquity as exclusively ‘Western.’
Chapter 7 explores the ephemeral image, transcended on the journey to truth. Emphasis on inward mimesis and perception through spiritual training shifts the art-historical emphasis on material objects toward a recognition of the importance of dreams, visions, and dematerializing images in Islamic discourses. The similar functions of the trope of the image and the dream image underscore their functional interchangeability as well as the reality often ascribed to dreams and visions over materiality. This emerges in uses of the image as identification; in Prophetic visions proving his miraculous journeys; ibn Arabi’s interpretation of sleep as a metaphor for exile in the Quranic parable of the Cave of the Seven Sleepers; and in the theorization of sleep and dreams as enabling an interface with reality impossible in the waking or material world. The resulting valorization of meaning over matter suggests a mode of preservation rooted in ideas rather than physical forms, accepted as inevitably perishable. Similar tropes of the image in Nizami’s Shirin and Khosrau, and Rumi’s story of the Three Princes, suggest that the image should be approached with neither love nor hate, but with indifference.