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Background Down Your Drink (DYD) is a widely used unguided web-based alcohol moderation program for the general public based on cognitive behavioral therapy (CBT) and motivational interviewing (MI); it provides users with many opportunities to enter free-text responses. Objective The aim of this study was to assess participants’ use of key CBT and MI components, the presence of change talk and sustain talk within their responses, and whether these data are associated with drinking outcomes after 3 months. Methods An exploratory secondary data analysis was conducted on data collected in 2008 from the definitive randomized trial of DYD (N=503). Past week alcohol use at baseline and 3-month follow-up were measured with the TOT-AL. Covariates included baseline alcohol use, age, gender, education level, and word count of the responses. Use of MI and CBT components and presence of change talk and sustain talk were coded by two independent coders (Cohen κ range 0.91-1). Linear model regressions on the subsample of active users (n=410) are presented along with a negative binomial regression. Results The most commonly used component was the listing of pros and cons of drinking. The number of listed high-risk situations was associated with lower alcohol use at 3-month follow-up (Badj −2.15, 95% CI −3.92 to −0.38, P=.02). Findings on the effects of the percentage of change talk and the number of listed strategies to deal with high-risk situations were inconsistent. Conclusions An unguided web-based alcohol moderation program can elicit change talk and sustain talk. This secondary analysis suggests that the number of listed high-risk situations can predict alcohol use at 3-month follow-up. Other components show inconsistent findings and should be studied further.

Background The public health message around alcohol is complex, with benefits versus harms, the confusing concept of risk and drinking guidance changing over time. This provides a difficult context for alcohol screening in primary care, with established barriers from the practitioner perspective, but less is known about the patients’ perspective. This study explores patients’ views on drinking. Methods Eligible participants were recorded as drinking above low risk levels in primary care. Six practices in North London participated. Interviews were in-depth, semi-structured, transcribed verbatim and underwent detailed thematic analysis. Findings Interviews were conducted with 8 women and 12 men, aged 26–83 years, mostly educated to undergraduate level and of ‘White’ ethnicity. UK drinking guidance was viewed as irrelevant for reasons related to life stage, lifestyle and absence of harm. Dependence, loss of functionality and control were perceived as key features of problematic drinking. Healthy lifestyles, in terms of diet, exercise and not smoking, were thought to mitigate potential problems associated with alcohol intake. Conclusion The findings suggest that public health messages and brief advice should focus on harm experienced at different life stages, among people with different lifestyles, to challenge the ubiquitous view that ‘I’m not a real boozer’.

BACKGROUND Down Your Drink (DYD) is a widely used unguided web-based alcohol moderation program for the general public based on cognitive behavioral therapy (CBT) and motivational interviewing (MI); it provides users with many opportunities to enter free-text responses. OBJECTIVE The aim of this study was to assess participants’ use of key CBT and MI components, the presence of change talk and sustain talk within their responses, and whether these data are associated with drinking outcomes after 3 months. METHODS An exploratory secondary data analysis was conducted on data collected in 2008 from the definitive randomized trial of DYD (N=503). Past week alcohol use at baseline and 3-month follow-up were measured with the TOT-AL. Covariates included baseline alcohol use, age, gender, education level, and word count of the responses. Use of MI and CBT components and presence of change talk and sustain talk were coded by two independent coders (Cohen κ range 0.91-1). Linear model regressions on the subsample of active users (n=410) are presented along with a negative binomial regression. RESULTS The most commonly used component was the listing of pros and cons of drinking. The number of listed high-risk situations was associated with lower alcohol use at 3-month follow-up (Badj −2.15, 95% CI −3.92 to −0.38, P=.02). Findings on the effects of the percentage of change talk and the number of listed strategies to deal with high-risk situations were inconsistent. CONCLUSIONS An unguided web-based alcohol moderation program can elicit change talk and sustain talk. This secondary analysis suggests that the number of listed high-risk situations can predict alcohol use at 3-month follow-up. Other components show inconsistent findings and should be studied further.

BACKGROUND Digital technology has been proposed to support health and wellbeing in those with complex mental health needs. OBJECTIVE The aim of this study was to investigate use of the internet by a group of service users with complex depression, anxiety and trauma and their attitudes and perspectives towards online help METHODS Mixed methods cross-sectional design using a survey and thematic analysis of individual semi-structured interviews. RESULTS 66 of 575 (11.5%) service users completed the survey. Most were female (63%), from a White British background (61.5%) and identified English as their first language (77%). 52% had more than one mental health diagnosis and on average had been in contact with mental health services for over 10 years. 67% had regular access to a smartphone and 64% to a laptop or desktop. Participants were reasonably confident using digital devices and had previously looked at mental health information online. Of those who had not 57% said they would consider doing so. Most had not accessed psychological treatment online, and 52% said they would not consider doing so. 27 service users participated in the interviews. Two main themes were derived: 1) motivators and 2) de-motivators of health-related internet use. Motivators included previous positive experiences online, perceived advantages, good website design and branding and individual enablers such as IT skills and improved mental state. De-motivators included previous unhelpful experiences resulting in negative emotions, unreliable or contradictory information and barriers such as poor design and interference due to mental health symptoms and avoidance. CONCLUSIONS Clinicians should routinely enquire about internet use in assessments and provide information to service users regarding recommended websites or apps. Education and support for service users to improve their e-health literacy may also be beneficial. Research including service users with severe and complex mood and anxiety disorders may help in improving the accessibility and use of online interventions by this group. CLINICALTRIAL Health Research Authority (IRAS 214069).

Alcohol consumption by young professional women is increasing. Whilst the media and public health campaigns have condemned this increase, societal attitudes and advertising discourses frame it as a display of “power femininity”. This qualitative study explored young professional women's “relationship with alcohol”: why they drank and how they felt about it. Twelve young professional women who reported drinking over official limits and had not sought professional help were recruited via UK public houses (drinking establishments, usually called pubs) and later interviewed. Transcripts were analysed thematically. Participants used alcohol to gain power; they saw drinking as a masculine ability demonstrating stamina, valued professionally and socially. However, women were also ashamed of their drinking; they felt criticised by health professionals and the media. Rather than perpetuating a blaming and shaming discourse, it may be important to counteract social norms associating alcohol use with power and sobriety with weakness.

Alcohol-use disorders are widespread and associated with a greatly increased risk of health-related and societal harms. The majority of harms associated with consumption are experienced by those who drink above recommended guidelines, rather than those who are alcohol dependent. Brief interventions and treatments based on screening questionnaires and feedback have been developed for this group, which are effective tools for reducing consumption in primary care and in other settings. Most people who drink excessively do not receive help to reduce the risks associated with excessive consumption. Digital versions of brief and extended interventions have the potential to reach populations that might derive benefit from them. Digital interventions utilize the same principles as do traditional face-to-face versions, but they have the advantages of availability, confidentiality, flexibility, low marginal costs, and treatment integrity. The evidence for the feasibility, acceptability, costs, and effectiveness of digital interventions is encouraging, and the evidence for effectiveness is particularly strong in studies of student populations. There are, however, a number of unresolved questions. It is not clear which components of interventions are required to maximize effectiveness, whether digital versions are enhanced by the addition of personal contact from a facilitator or a health professional, or how to increase take up of the offer of a digital intervention and reduce attrition from a program. These questions are common to many online behavior-change interventions and there are opportunities for cross-disciplinary learning between psychologists, health professionals, computer scientists, and e-health researchers.

Fathers, in general, have been underrepresented in studies of parent training outcome for children with attention deficit hyperactivity disorder (ADHD), and the present study aimed to investigate the efficacy of a behavioral parent training program developed expressly for fathers. The present investigation randomly assigned 55 fathers of children ages 6 to 12 with ADHD to the Coaching Our Acting-out Children: Heightening Essential Skills (COACHES) program or a waitlist control group. Outcomes for the study included objective observations of parent behaviors and parent ratings of child behavior. Results indicated that fathers in the COACHES group reduced their rates of negative talk and increased rates of praise as measured in parent-child observations, and father ratings of the intensity of problem behaviors were reduced, relative to the waitlist condition. Groups did not differ on observations of use of commands or father ratings of child behavior problems. Untreated mothers did not significantly improve on observational measures or behavioral ratings. This study provides preliminary evidence for the efficacy of the COACHES parenting program for fathers of children with ADHD. Results are cast in light of the larger literature on behavioral parent training for ADHD as well as how to best work with fathers of children with ADHD in treatment contexts.

Aims: Defensiveness in response to threatening health information related to excessive alcohol consumption prevents appropriate behaviour change. Alternatively, self-affirmation may improve cognitive-affective processing of threatening information, thus contributing to successful self-regulation.\ud \ud Methods: Effects of an online self-affirmation procedure were examined in at-risk university student drinkers. Participants were randomly assigned to a self-affirmation (writing about personally relevant values) or control task (writing about values relevant to another person) prior to presentation of alcohol-related threatening information. Assessment of prosocial feelings (e.g. ‘love’) after the task served as a manipulation check. Generic and personalized information regarding the link between alcohol use and cancer was presented, followed by assessment of perceived threat, message avoidance and derogation. Page dwell-times served as indirect indices of message engagement. Alcohol consumption and intention to drink less were assessed during the first online session and at 1-week and 1-month follow-up.\ud \ud Results: Although self-affirmation resulted in higher levels of prosocial feelings immediately after the task, there was no effect on behaviour in the self-affirmation group. Effects on intention were moderated by gender, such that men showed lower intention immediately after self-affirmation, but this increased at 1-week follow-up. Women's intention to reduce consumption in the self-affirmation group reduced over time. Trend-level effects on indices of derogation and message acceptance were in the predicted direction only in men.\ud \ud Conclusion: It is feasible to perform self-affirmation procedures in an online environment with at-risk drinkers. However, use of internet-based procedures with this population may give rise to (gender-dependent) effects that are substantially diluted compared with lab-based experiments.

Background: Copying to patients the letters sent between health professionals is an increasing trend and in the UK National Health Service has become a national requirement.Aims: To explore patients' immediate reactions to, and views of, the routine clinical assessment letters that their psychiatrists and psychologists send to their referring general practitioner (GP).Methods: Thirty-two outpatients, most with depression or anxiety disorders, were interviewed and asked their views of the letter sent by their psychiatrist or psychologist to their GP.Results: Patients were generally satisfied with their letters. The letters were considered accurate, clear and comprehensive. Drugs, sex and unfavourable history about family members were identified as sensitive areas. Realizing their psychiatrist or psychologist had understood and taken on board their problems, better understanding of their problems, feeling greater involvement in their care, being able to correct misunderstandings, and being able to show sign...

Aims: To conduct a pilot study of the usefulness of Down Your Drink (DYD), a web-based intervention to encourage excessive drinkers to adopt a healthy pattern of drinking and reduce alcohol-associated harm. The DYD website was structured as a 6-week programme, derived from a manual which included elements of motivational approaches and cognitive behavioural therapy. Methods: Visitors whose responses to the Fast Alcohol Screening Test were positive, and those indicating excessive alcohol con- sumption, were encouraged to register. Users completed alcohol dependence and mental health questionnaires before the programme, and a drinking diary at each of the weekly sessions. Follow-up questionnaires were sent electronically to those who completed the programme, or who missed three or more sessions. Results: During the 6-month study there were 7581 visits to the site and 1319 registrations. Of the registrants, 61.8% completed week 1, and 6.0% stayed with the programme until the end. The 6% who stayed for 6 weeks provided encouraging feedback about the value of the site. Little information was obtained from those who dropped out, but some reported that the programme was too time-consuming. Conclusions: Web site interventions for excessive drinkers are feasible and merit evaluation of their effectiveness.

BackgroundAlcohol misuse in England costs around £7.3 billion (US$12.2 billion) annually from lost productivity and absenteeism. Delivering brief alcohol interventions to employees as part of a health check may be acceptable, particularly with online delivery which can provide privacy for this stigmatised behaviour. Research to support this approach is limited and methodologically weak. The aim was to determine the effectiveness of online screening and personalised feedback on alcohol consumption, delivered in a workplace as part of a health check.Methods and findingsThis two-group online individually randomised controlled trial recruited employees from a UK-based private sector organisation (approx. 100,000 employees). 3,375 employees completed the online health check in the three week recruitment period. Of these, 1,330 (39%) scored five or more on the AUDIT-C (indicating alcohol misuse) and were randomised to receive personalised feedback on their alcohol intake, alongside feedback on other health behaviours (n = 659), or to receive feedback on all health behaviours except alcohol intake (n = 671). Participants were mostly male (75%), with a median age of 48 years and half were in managerial positions (55%). Median Body Mass Index was 26, 12% were smokers, median time undertaking moderate/vigorous physical activity a week was 173 minutes and median fruit and vegetable consumption was three portions a day. Eighty percent (n = 1,066) of participants completed follow-up questionnaires at three months. An intention to treat analysis found no difference between experimental groups for past week drinking (primary outcome) (5.6% increase associated with the intervention (95% CI -4.7% to 16.9%; p = .30)), AUDIT (measure of alcohol-related harm) and health utility (EQ-5D).ConclusionsThere was no evidence to support the use of personalised feedback within an online health check for reducing alcohol consumption among employees in this organisation. Further research is needed on how to engage a larger proportion of employees in screening.Trial registrationInternational Standard Randomised Controlled Trial Number Register ISRCTN50658915.

Purpose To investigate the ability of the EQ-5D to discriminate between levels of alcohol risk in a large sample of hazardous and harmful drinkers, and to explore the relationship between transitions between alcohol risk levels and changes in EQ-5D up to 12 months. Methods This is a web-based randomised controlled trial evaluating a novel intervention for hazardous and harmful alcohol consumption. EQ-5D scores were compared among groups of drinkers at baseline (low/medium/high risk according to self-reported past week alcohol consumption), and changes in EQ-5D scores were estimated as a function of changes in alcohol consumption level. Results Baseline EQ-5D scores were dominated by problems with anxiety/depression, which increased with alcohol risk level, whilst high-risk drinkers also experienced more problems with physical HRQoL dimensions. However, the tool demonstrated a considerable ceiling effect. At follow-up, despite considerable reductions in alcohol consumption across the sample, significant changes in aggregated EQ-5D index scores were only observed for high-risk drinkers at baseline who reduced their drinking, with small improvements (0.04‐0.06) compared to those who did not reduce. Conclusions Our results suggest that the three-option EQ5D may not be an optimal primary end point for measuring clinical and cost-effectiveness in randomised controlled trials of interventions among hazardous and harmful alcohol users, although further testing of the sensitivity of the tool in these populations is needed.

were mostly male (75%), married (77%) with relatively healthy lifestyles. There was no significan td ifference between groups for any outcome. Both groups reduced their median AUDIT-C score by 1. Only 19 participants registered with the DYD website for further help to reduce their drinking. Conclusions In the context of an online health check, this pragmatic trial did not find brief advice to reduce alcohol intake when compared with no feedback. Completion of the AUDIT-C alone may have led both groups to reduce their drinking slightly.

Background: Alcohol misuse is a significant international public health problem. Screening and brief intervention (SBI) in primary care reduces alcohol consumption by about 15 – 30%, sustained over 12 months in hazardous or harmful drinkers but implementation has proved difficult leading to growing interest in exploring the effectiveness of SBI in other settings, including the workplace. Computerised interventions for alcohol misuse can be as effective as traditional face-to-face interventions and may have advantages, including anonymity, convenience and availability. Methods/design: Individually randomised controlled trial to determine the effectiveness and cost-effectiveness of offering online screening and brief intervention for alcohol misuse in a workplace. Participants: adults (aged 18 or over) employed by participating employers scoring 5 or more on a three item screen for alcohol misuse (the AUDIT-C) indicating possible hazardous or harmful alcohol consumption, recruited through the offer of an online health check providing screening for a range of health behaviours with personalised feedback. Participants who accept the health check and score 5 or more on the alcohol screen will be randomised to receiving immediate feedback on their alcohol consumption and access to an online intervention offering support in reducing alcohol consumption (Down Your Drink) or delayed feedback and access to Down Your Drink after completion of follow-up data at three months. All employees who take the online health check will receive personalised feedback on other screened health behaviours including diet, physical activity, smoking, and body mass index. The primary outcome is alcohol consumption in the past week at three months; secondary outcomes are the AUDIT, EQ-5D, days off work, number and duration of hospital admissions, costs and use of the intervention. A sample size of 1,472 participants (736 in each arm) provides 90% power with 5% significance to determine a 20% reduction in alcohol consumption. Outcomes between groups at three months will be compared following the intention to treat principle and economic analyses will follow NICE guidance. Discussion: This innovative design avoids recruitment bias by not mentioning alcohol in the invitation and avoids reactivity of assessment by not collecting baseline data on alcohol consumption.

Aims : To describe the development and evaluation of an innovative web-based service for hazardous or harmful drinkers. Methods : Patients were identified in General Practice and referred to the new service. Mixed methods were used for evaluation. Results : The service was feasible and acceptable to patients, primary care professionals and commissioners. Users appeared to reduce their alcohol consumption. Conclusion : This model may be of interest to other primary care commissioners looking to increase access to alcohol treatments at low cost.

Aims and MethodThe study investigated the personal impact of patient suicides on the members of community mental health teams and the sources of support utilised for coping with adverse effects.ResultsForty-four questionnaires were returned. Eighty-six per cent of staff reported having had at least one patient suicide, with an average of 4.2 suicides. The majority of staff reported that patient suicides had significant adverse effects on their personal and professional lives. Some of the effects were long-lasting (greater than 1 month). Staff found that peer support, reviews, dedicated staff meetings and support from senior colleagues were of most value.Clinical ImplicationsStaff require skilled and dedicated support following a patient suicide in order to minimise its detrimental effects on personal, professional and team functioning.

BackgroundThere has been limited study of factors influencing response rates and attrition in online research. Online experiments were nested within the pilot (study 1, n = 3780) and main trial (study 2, n = 2667) phases of an evaluation of a Web-based intervention for hazardous drinkers: the Down Your Drink randomized controlled trial (DYD-RCT). ObjectivesThe objective was to determine whether differences in the length and relevance of questionnaires can impact upon loss to follow-up in online trials. MethodsA randomized controlled trial design was used. All participants who consented to enter DYD-RCT and completed the primary outcome questionnaires were randomized to complete one of four secondary outcome questionnaires at baseline and at follow-up. These questionnaires varied in length (additional 23 or 34 versus 10 items) and relevance (alcohol problems versus mental health). The outcome measure was the proportion of participants who completed follow-up at each of two follow-up intervals: study 1 after 1 and 3 months and study 2 after 3 and 12 months. ResultsAt all four follow-up intervals there were no significant effects of additional questionnaire length on follow-up. Randomization to the less relevant questionnaire resulted in significantly lower rates of follow-up in two of the four assessments made (absolute difference of 4%, 95% confidence interval [CI] 0%-8%, in both study 1 after 1 month and in study 2 after 12 months). A post hoc pooled analysis across all four follow-up intervals found this effect of marginal statistical significance (unadjusted difference, 3%, range 1%-5%, P = .01; difference adjusted for prespecified covariates, 3%, range 0%-5%, P = .05). ConclusionsApparently minor differences in study design decisions may have a measurable impact on attrition in trials. Further investigation is warranted of the impact of the relevance of outcome measures on follow-up rates and, more broadly, of the consequences of what we ask participants to do when we invite them to take part in research studies. Trial registrationISRCTN Register 31070347; http://www.controlled-trials.com/ISRCTN31070347/31070347 Archived by WebCite at (http://www.webcitation.org/62cpeyYaY)

BACKGROUND: Interventions delivered via the Internet have the potential to address the problem of hazardous alcohol consumption at minimal incremental cost, with potentially major public health implications. It was hypothesised that providing access to a psychologically enhanced website would result in greater reductions in drinking and related problems than giving access to a typical alcohol website simply providing information on potential harms of alcohol. DYD-RCT Trial registration: ISRCTN 31070347. METHODOLOGY/PRINCIPAL FINDINGS: A two-arm randomised controlled trial was conducted entirely on-line through the Down Your Drink (DYD) website. A total of 7935 individuals who screened positive for hazardous alcohol consumption were recruited and randomized. At entry to the trial, the geometric mean reported past week alcohol consumption was 46.0 (SD 31.2) units. Consumption levels reduced substantially in both groups at the principal 3 month assessment point to an average of 26.0 (SD 22.3) units. Similar changes were reported at 1 month and 12 months. There were no significant differences between the groups for either alcohol consumption at 3 months (intervention: control ratio of geometric means 1.03, 95% CI 0.97 to 1.10) or for this outcome and the main secondary outcomes at any of the assessments. The results were not materially changed following imputation of missing values, nor was there any evidence that the impact of the intervention varied with baseline measures or level of exposure to the intervention. CONCLUSIONS/SIGNIFICANCE: Findings did not provide support for the hypothesis that access to a psychologically enhanced website confers additional benefit over standard practice and indicate the need for further research to optimise the effectiveness of Internet-based behavioural interventions. The trial demonstrates a widespread and potentially sustainable demand for Internet based interventions for people with hazardous alcohol consumption, which could be delivered internationally. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN31070347.

AIMS: The content of novel interventions is often not well specified. We provide a detailed account of the rationale for and redevelopment of an Internet resource for hazardous drinkers-Down Your Drink (DYD) (www.downyourdrink.org.uk). DEVELOPMENT WORK: An iterative process blended literature reviews of Internet interventions for health conditions and brief treatments for alcohol problems, feedback from users of the original site and from users panels, and completion of a series of developmental tasks. INTERVENTION: The detailed structure and content of the new version of the website is presented. This permits an appreciation of the intended interaction between the user and the intervention, and emphasizes both the freedom of choice available to the user to access diverse material for personal benefit and the value of a clear organizational structure. CONCLUSIONS: Presentation of detailed information on the theoretical underpinning, content and structure of an intervention makes it easier to interpret the results of any evaluation and is likely to be of use to those developing other online interventions for alcohol or other health behaviours.

The conference address by Thomas MacKay and the editorial comment which accompanied it were published in the June 1981 issue of Apex with the aim of stimulating discussion of this very controversial subject. This aim has been achieved and the first replies received are set out in the following pages. Further comments from readers for inclusion in future issues are welcome. An early response is advised for those wishing to be included in the March issue, at which time a follow-up article by Mr. MacKay is to appear.

Background The practical and methodological challenges inherent in online behaviour change studies are both novel and complex. We relate our experiences of estimating and managing information technology (IT) research and intervention costs in an ongoing internet trial in the hope that others will find this information useful. Findings Actual IT costs were approximately twice those that had been originally estimated by external contractors. These original estimates for IT costs allowed little scope for the identification of new needs, which was intrinsic to the iterative nature of the research enterprise. Conclusions Making greater provision for the uncertain nature of these costs in future studies is a key practical lesson for the planning of future online behaviour change studies.

Background Heavy drinking is responsible for major health and social problems. Brief interventions have been shown to be effective, but there have been difficulties in reaching those who might benefit from them. Pilot studies have indicated that a Web-based intervention is likely to be acceptable to heavy drinkers and may produce some health benefits. However, there are few data on how many people might use such a program, the patterns of use, and potential benefits. Objectives The aim was to examine the demographic characteristics of users of a free, Web-based, 6-week intervention for heavy drinkers and to describe the methods by which users identified the site, the pattern of site use and attrition, the characteristics associated with completing the program, and the self-reported impact on alcohol-related outcomes. Methods Cohort study. Visitors to the Web site were offered screening with the Fast Alcohol Screening Test, and those scoring above the cutoff for risky drinking were invited to register with the program. Demographic information was collected routinely at registration, and questionnaires were completed at the end of weeks 1 and 6. The outcome measures assessed dependency (Short Alcohol Dependency Data Questionnaire), harms (modified Alcohol Problems Questionnaire), and mental health (Clinical Outcomes in Routine Evaluation–Outcome Measure). Results The records of 10000 users were analyzed. The mean age was 37.4 years, 51.1% were female, 37.5% were single, and 42.4% lived with children. The majority were White British, lived in the United Kingdom, and reported occupations from the higher socioeconomic strata. Over 70% connected to the Down Your Drink (Down Your Drink) site from another Internet-based resource, whereas only 5.8% heard about the site from a health or other professional. Much of the Web site use (40%) was outside normal working hours. Attrition from the program was high, with only 16.5% of registrants completing the whole 6 weeks. For those who completed the program, and the final outcome measures, measures of dependency, alcohol-related problems, and mental health symptoms were all reduced at week 6. Conclusions The Web-based intervention was highly used, and those who stayed with the program showed significant reductions in self-reported indicators of dependency, alcohol-related problems, and mental health symptoms; however, this association cannot be assumed to be causal. Programs of this type may have the potential to reach large numbers of heavy drinkers who might not otherwise seek help. There are significant methodological challenges and further research is needed to fully evaluate such interventions.

The functions of resistance and restraint are considered in three topographically distinct psychological disorders that are characterized by excessive behaviour. Certain similarities are observed and speculations about their common role are examined. Finally attention is drawn to the implications of this type of analysis for our understanding of such disorders and for psychological treatment.

Dependency levels of long-term mentally disabled people in hospital and community settings were compared using a behavioural rating scale called REHAB in a health district where a policy of community care had been implemented. It was found that the performance of subjects in the community settings was better than those on the admission ward, but was worse than half the people normally found in traditional psychiatric settings. The policy of community care would seem to have been successful insofar as this group of subjects was able to remain in community settings. Comparison of the REHAB factor scores suggested differences in the behavioural competence of subjects supported by community psychiatric nurses and social services staff compared to those attending a psychiatric day hospital.

THE level of alcohol, tobacco, solvent and drug use by 1882 school children aged between 14 and 15 years within Pontefract Health District was examined by means of a questionnaire. Alcohol and tobacco use was relatively high, and comparable to similar studies elsewhere. The use of substances other than alcohol and tobacco was reported by a much lower percentage. Behavioural factors associated with sub stance use were examined, and implications for health education suggested.

In an uncontrolled pilot study of an interactive, Web-based treatment programme for people with alcohol problems, the mean number of units consumed decreased from 33 per week to 23. A two-arm online randomized controlled trial will be conducted to determine the effectiveness of an interactive Web-based intervention for reducing alcohol consumption. Participants will be randomized to intervention (access to an interactive Web-based intervention plus information) or control (access to an information Website only) groups, and followed up for six months. The primary outcome measure will be reduction in units of alcohol consumed in the previous seven days; secondary outcome measures will determine effects on alcohol dependence, alcohol-related harm and social disruption and quality of life. Recruitment, consent, randomization, intervention and follow-up will all be delivered online.

Background Excessive alcohol consumption is a significant public health problem throughout the world. Although there are a range of effective interventions to help heavy drinkers reduce their alcohol consumption, these have little proven population-level impact. Researchers internationally are looking at the potential of Internet interventions in this area. Methods/Design In a two-arm randomised controlled trial, an on-line psychologically enhanced interactive computer-based intervention is compared with a flat, text-based information web-site. Recruitment, consent, randomisation and data collection are all on-line. The primary outcome is total past-week alcohol consumption; secondary outcomes include hazardous or harmful drinking, dependence, harm caused by alcohol, and mental health. A health economic analysis is included. Discussion This trial will provide information on the effectiveness and cost-effectiveness of an on-line intervention to help heavy drinkers drink less. Trial registration International Standard Randomised Controlled Trial Number Register ISRCTN31070347

Challenging behaviors are one of the most common concerns of early educators, and preschool teachers continue to report feeling unprepared to meet the needs of children displaying challenging behaviors. Overall, traditional standardized classroom assessments have evaluated global classroom quality, but they may not capture the reciprocal and recursive nature of interactions present in preschool classrooms in a manner that can be easily quantified. The current investigation presents initial psychometric information for the Student Behavior Teacher Response (SBTR) observation scheme, a measure that captures instances of challenging behavior and the teacher’s response to the behavior. In a sample of 88 Head Start teachers, the observation system exhibited preliminary evidence of inter-rater score agreement and reliability, as well as convergent and discriminant validity. Implications for educators and early childhood assessments are discussed.