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To understand how exposure to victimization during adolescence and the presence of comorbid psychological conditions influence substance use treatment entry and substance use disorder diagnosis from 14 to 25 years old among serious juvenile offenders, this study included 1,354 serious juvenile offenders who were prospectively followed over 7 years. Growth mixture modeling was used to assess profiles of early victimization during adolescence (14–17 years). Discrete time survival mixture analysis was used to assess time to treatment entry and substance use disorder diagnosis. Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) were used as predictors of survival time. Mixture models revealed three profiles of victimization: sustained poly-victimization, moderate/decreasing victimization, and low victimization. Youth in the sustained poly-victimization class were more likely to enter treatment earlier and have a substance use diagnosis earlier than other classes. PTSD was a significant predictor of treatment entry for youth in the sustained poly-victimization class, and MDD was a significant predictor of substance use disorder diagnosis for youth in the moderate/decreasing victimization class. Therefore, substance use prevention programming targeted at youth experiencing poly-victimization in early adolescence—especially those who have PTSD or MDD—is needed.
Cognitive-behavioural therapy (CBT) is an effective treatment for depressed adults. CBT interventions are complex, as they include multiple content components and can be delivered in different ways. We compared the effectiveness of different types of therapy, different components and combinations of components and aspects of delivery used in CBT interventions for adult depression. We conducted a systematic review of randomised controlled trials in adults with a primary diagnosis of depression, which included a CBT intervention. Outcomes were pooled using a component-level network meta-analysis. Our primary analysis classified interventions according to the type of therapy and delivery mode. We also fitted more advanced models to examine the effectiveness of each content component or combination of components. We included 91 studies and found strong evidence that CBT interventions yielded a larger short-term decrease in depression scores compared to treatment-as-usual, with a standardised difference in mean change of −1.11 (95% credible interval −1.62 to −0.60) for face-to-face CBT, −1.06 (−2.05 to −0.08) for hybrid CBT, and −0.59 (−1.20 to 0.02) for multimedia CBT, whereas wait list control showed a detrimental effect of 0.72 (0.09 to 1.35). We found no evidence of specific effects of any content components or combinations of components. Technology is increasingly used in the context of CBT interventions for depression. Multimedia and hybrid CBT might be as effective as face-to-face CBT, although results need to be interpreted cautiously. The effectiveness of specific combinations of content components and delivery formats remain unclear. Wait list controls should be avoided if possible.
Social network characteristics of people who inject drugs (PWID) have previously been flagged as potential risk factors for HCV transmission such as increased injection frequency. To understand the role of the injecting network on injection frequency, we investigated how changes in an injecting network over time can modulate injecting risk behaviour. PWID were sourced from the Networks 2 Study, a longitudinal cohort study of PWID recruited from illicit drug street markets across Melbourne, Australia. Network-related correlates of injection frequency and the change in frequency over time were analysed using adjusted Cox Proportional Hazards and Generalised Estimating Equations modelling. Two-hundred and eighteen PWID followed up for a mean (s.d.) of 2.8 (1.7) years were included in the analysis. A greater number of injecting partners, network closeness centrality and eigenvector centrality over time were associated with an increased rate of infection frequency. Every additional injection drug partner was associated with an increase in monthly injection frequency. Similarly, increased network connectivity and centrality over time was also associated with an increase in injection frequency. This study observed that baseline network measures of connectivity and centrality may be associated with changes in injection frequency and, by extension, may predict subsequent HCV transmission risk. Longitudinal changes in network position were observed to correlate with changes in injection frequency, with PWID who migrate from the densely-connected network centre out to the less-connected periphery were associated with a decreased rate of injection frequency.
The Frequent Attenders Programme is a joint initiative between Hertfordshire Rapid Assessment, Interface and Discharge service and the Emergency Department of the West Hertfordshire NHS Trust, which aims to divert frequent attenders from the emergency department by addressing their unmet needs. This paper describes the range of interventions put in place from the time that the service was set up in 2014 until the introduction of the new national Commissioning for Quality and Innovation 2017–2019, which tasked National Health Service trusts to improve services for people with mental health needs who present to Accident and Emergency. The terms emergency department and Accident and Emergency are used interchangeably, reflecting the practice in policy documents. A subsequent article will report on the impact of the Commissioning for Quality and Innovation in Hertfordshire.
Analysis of the interventions indicated a highly significant (P < 0.0001) mean reduction in attendances. Lower gains were made in patients whose primary presentations were alcohol-related. A failure to effect change in two patients led to a significant revision of their respective care plans, resulting in a subsequent reduction in their attendances.
An integrated approach to patients with complex presentations was associated with high levels of both patient and referrer satisfaction. It is hypothesised that dismantling the barriers between physical and mental health may lead to similar successes in frequent attenders in other in-patient and community medical and psychiatric services.
NHS Foundation Trust (FT) hospitals in England have complex internal governance arrangements. They may be considered to exhibit meta-regulatory characteristics to the extent that governors are able to promote deliberative values and steer internal governance processes towards wider regulatory goals. Yet, while recent studies of NHS FT hospital governance have explored FT governors and examined FT hospital boards to consider executive oversight, there is currently no detailed investigation of interactions between these two groups. Drawing on observational and interview data from four case-study sites, we trace interactions between the actors involved; explore their understandings of events; and consider the extent to which the proposed benefits of meta-regulation were realised in practice. Findings show that while governors provided both a conscience and contribution to internal and external governance arrangements, the meta-regulatory role was largely symbolic and limited to compliance and legitimation of executive actions. Thus while the meta-regulatory ‘architecture’ for governor involvement may be considered effective, the soft intelligence gleaned and operationalised may be obscured by ‘hard’ performance metrics which dominate resource-allocation processes and priority-setting. Governors were involved in practices that symbolised deliberative involvement but resulted in further opportunities for legitimising executive decisions.
The role of basal melting within high-precipitation temperate glaciers represents a significant gap in understanding glacier melting processes. We use a basal melt equation to calculate geothermal and frictional heat-induced basal melt and develop an equation to calculate the rainfall-induced basal melt for Franz Josef Glacier, New Zealand, a high-precipitation, temperate glacier. Additionally, we calculate basal melt due to heat dissipation within water and ice. Data collated from published information on glacier dynamics and climate station readings show that total basal melt contributes on average ∼2.50 m a−1 over the lower to mid-ablation zone (300–1500 m a.s.l.), which is equivalent to >10% of the total ablation for the glacier. This indicates that basal melting is an important component of mass balance for high-precipitation, temperate glaciers.
Here we report a laboratory study of the effects of debris thickness, diurnally cyclic radiation and rainfall on melt rates beneath rock-avalanche debris and sand (representing typical highly permeable supraglacial debris). Under continuous, steady-state radiation, sand cover >50 mm thick delays the onset of ice-surface melting by >12 hours, but subsequent melting matches melt rates of a bare ice surface. Only when diurnal cycles of radiation are imposed does the debris reduce the longterm rate of ice melt beneath it. This is because debris >50 mm thick never reaches a steady-state heat flux, and heat acquired during the light part of the cycle is partially dissipated to the atmosphere during the nocturnal part of the cycle, thereby continuously reducing total heat flux to the ice surface underneath. The thicker the debris, the greater this effect. Rain advects heat from high-permeability supraglacial debris to the ice surface, thereby increasing ablation where thin, highly porous material covers the ice. In contrast, low-permeability rock-avalanche material slows water percolation, and heat transfer through the debris can cease when interstitial water freezes during the cold/night part of the cycle. This frozen interstitial water blocks heat advection to the ice–debris contact during the warm/day part of the cycle, thereby reducing overall ablation. The presence of metre-deep rock-avalanche debris over much of the ablation zone of a glacier can significantly affect the mass balance, and thus the motion, of a glacier. The length and thermal intensity of the diurnal cycle are important controls on ablation, and thus both geographical location and altitude significantly affect the impact of debris on glacial melting rates; the effect of debris cover is magnified at high altitude and in lower latitudes.
‘“It all comes”, said Pooh crossly, “of not having front doors big enough.”’
A. A. Milne, Winnie the Pooh
Despite the development of home treatment teams and early intervention psychosis services, the demand for in-patient child and adolescent beds remains. It is rare for young people with mental disorders to require inpatient services, but when they do, beds are few and far between. Reasons for admission include severity of illness, deterioration in psychological functioning despite community treatment, high risk to self or others, or family difficulties making treatment difficult, any of which may lead to the need for 24-hour care (Green & Worrall-Davies, 2008). In-patient care is a specialised field providing treatment for young people with serious psychiatric illness by skilled and experienced staff.
Who and what are in-patient units for?
There is a range of psychiatric, educational, social, criminal and societal indicators for admission to an in-patient service. It is usually impossible to separate the different aspects or contributors to the young person's disorder so that each can be provided by the different agencies responsible for it. Psychological disorders, because of adverse life experiences, are common and pure psychiatric disorders are rare, but they all have educational and social precursors and sequelae. Trying to compartmentalise children into unidisciplinary treatment pigeonholes is problematic as:
• admission to psychiatric in-patient units considerably disrupts education and the young person's functioning in the community
• education authorities have to meet young people's special educational needs but cannot isolate these from other social and mental health factors, which they often do not have the resources to address
• residential policies of Social Services departments tend to address young people's mental health and educational needs only as secondary considerations
• the Home Office and Ministry of Justice, which will provide care in a prison setting, have little investment in childhood preventative work for the large proportion of young people with conduct disorder and complex needs when they become adults.
Work on sharing residential responsibility and input requires considerable inter-departmental and inter-agency working, but each agency will be uncertain who is going to reap the most for investing in them, and the harvest is not guaranteed.
Tier 4 CAMHS aim to meet the needs of children and young people with the most complex, severe or persistent mental health problems. Tier 4 services include in-patient care (see Chapter 29), as well as a range of day care and intensive community home-based and outreach services for specific groups of children and young people.
Early descriptions of child and adolescent mental health day units emphasised 5-day ‘milieu’ provision with a strong emphasis on education and behaviour management (Brown, 1996), whereas now they frequently provide daily focused activities to which children and families are invited, depending on their needs. Currently, about half of UK day services are linked to in-patient units, and many in-patient units have a day programme (Green & Jacobs, 1998). It is impossible to classify day services owing to the enormous range in milieu and interventions provided (Green & Worrall- Davies, 2008). However, day services broadly offer:
• support and transition to community services following in-patient admission;
• intensive 5 days per week treatment packages for children and their families;
• treatment of disruptive behaviour, using multimodal treatment strategies with a combination of individual, family and psychopharmacological interventions;
• specialist management and programmes of care for younger children with developmental disorders such as autism, speech and language disorders or neuropsychiatric disorders;
• intensive intervention aimed at improving family functioning in situations of family breakdown or child maltreatment.
Provision and organisation
Day units can offer assessment and therapeutic services that are more specialised, complex and intensive than out-patient services, although they are still community-based and less disruptive than in-patient admission. Most also have the benefit of educational input. Close liaison with specialised education and Social Services is central to their work. There is general acceptance of the central importance of maintaining attachments and working with whole systems if the complex needs of children are to be met. Day units can work with children and young people individually and in groups, as well as with their families, while keeping the focus of concern within the community and avoiding the ‘out of sight, out of mind’ dilemma of in-patient services.
Confronting national, linguistic and disciplinary boundaries, contributors to African Archaeology Without Frontiers argue against artificial limits and divisions created through the study of ‘ages’ that in reality overlap and cannot and should not be understood in isolation. Papers are drawn from the proceedings of the landmark 14th PanAfrican Archaeological Association Congress, held in Johannesburg in 2014, nearly seven decades after the conference planned for 1951 was re-located to Algiers for ideological reasons following the National Party’s rise to power in South Africa. Contributions by keynote speakers Chapurukha Kusimba and Akin Ogundiran encourage African archaeologists to practise an archaeology that collaborates across many related fields of study to enrich our understanding of the past. The nine papers cover a broad geographical sweep by incorporating material on ongoing projects throughout the continent including South Africa, Botswana, Cameroon, Togo, Tanzania, Kenya and Nigeria. Thematically, the papers included in the volume address issues of identity and interaction, and the need to balance cultural heritage management and sustainable development derived from a continent racked by social inequalities and crippling poverty. Edited by three leading archaeologists, the collection covers many aspects of African archaeology, and a range of periods from the earliest hominins to the historical period. It will appeal to specialists and interested amateurs.
Burnt mounds, or fulachtaí fiadh as they are known in Ireland, are probably the most common prehistoric site type in Ireland and Britain. Typically Middle–Late Bronze Age in age (although both earlier and later examples are known), they are artefact-poor and rarely associated with settlements. The function of these sites has been much debated with the most commonly cited uses being for cooking, as steam baths or saunas, for brewing, tanning, or textile processing. A number of major infrastructural development schemes in Ireland in the years 2002–2007 revealed remarkable numbers of these mounds often associated with wood-lined troughs, many of which were extremely well-preserved. This afforded an opportunity to investigate them as landscape features using environmental techniques – specifically plant macrofossils and charcoal, pollen, beetles, and multi-element analyses. This paper summarises the results from eight sites from Ireland and compares them with burnt mound sites in Great Britain. The fulachtaí fiadh which are generally in clusters, are all groundwater-fed by springs, along floodplains and at the bases of slopes. The sites are associated with the clearance of wet woodland for fuel; most had evidence of nearby agriculture and all revealed low levels of grazing. Multi-element analysis at two sites revealed elevated heavy metal concentrations suggesting that off-site soil, ash or urine had been used in the trough. Overall the evidence suggests that the most likely function for these sites is textile production involving both cleaning and/or dyeing of wool and/or natural plant fibres and as a functionally related activity to hide cleaning and tanning. Whilst further research is clearly needed to confirm if fulachtaí fiadh are part of the ‘textile revolution’ we should also recognise their important role in the rapid deforestation of the wetter parts of primary woodland and the expansion of agriculture into marginal areas during the Irish and British Bronze Ages.
Conservation planning often relies on measures such as species richness and abundance to prioritize areas for protection. Nonetheless, alternative metrics such as functional traits have recently been shown to be useful complementary measures for detecting biological change. Timely conservation planning often precludes the collection of such detailed biological data relying instead on remotely-sensed habitat mapping as a surrogate for diversity. While there is evidence that habitat maps may predict taxonomic species richness and diversity in some coastal ecosystems, it is unknown whether similar strong relationships exist for functional traits and functional multimetrics. We compared the performance of physical habitat structural complexity obtained from high definition swath mapping in explaining variation in traditional taxonomic metrics as well as functional traits (e.g., maximum length, trophic level, gregariousness) and functional multimetrics (e.g., functional richness, dispersion) of fish assemblages. Reef complexity measures were good surrogates for fish species richness and abundance but not for functional traits or multimetrics, except functional richness at the scale of 1 m. Remotely sensed habitat maps may not be a good surrogate for predicting functional traits and multimetrics of fish assemblages, and must be used with caution when maximizing such aspects of assemblages is a priority for conservation planning.