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Study Objectives Sleep quality is associated with different aspects of psychopathology, but relatively little research has examined links between sleep quality and externalizing behaviors or callous-unemotional traits. We examined: (1) whether an association exists between sleep quality and externalizing behaviors; (2) whether anxiety mediates this association; (3) whether callous-unemotional traits are associated with sleep quality. Methods Data from two studies were used. Study 1 involved 1556 participants of the G1219 study aged 18–27 years (62% female). Questionnaire measures assessed sleep quality, anxiety, externalizing behaviors, and callous-unemotional traits. Study 2 involved 338 participants aged 18–66 years (65% female). Questionnaires measured sleep quality, externalizing behaviors, and callous-unemotional traits. In order to assess objective sleep quality, actigraphic data were also recorded for a week from a subsample of study 2 participants (n = 43). Results In study 1, poorer sleep quality was associated with greater externalizing behaviors. This association was partially mediated by anxiety and moderated by levels of callous-unemotional traits. There was no significant relationship between sleep quality and callous-unemotional traits. In study 2, poorer sleep quality, as assessed via self-reported but not objective measures, was associated with higher levels of externalizing behaviors. Furthermore, in study 2, better sleep quality (indicated in both questionnaires and actigraphy measures: lower mean activity, and greater sleep efficiency) was associated with higher levels of callous-unemotional traits. Conclusions Self-reports of poorer sleep quality are associated with externalizing behaviors, and this association is partially mediated by anxiety. Callous-unemotional traits are not associated with poor sleep and may even be related to better sleep quality. This is an exceptional finding given that poor sleep quality appears to be a characteristic of most psychopathology.

Objectives\ud \ud The use of nutritional supplements has been associated with stronger doping intentions and actual use of doping substances, but there is limited research about doping risk communication among nutritional supplement users. The present study examined if using a self-affirmation manipulation a) changes intentions to use doping and b) influences related social cognitions (i.e., attitudes, social and moral norms, self-efficacy and situational temptation, and anticipated regret) among exercisers who use nutritional supplements, following a brief exposure to doping-related health risk messages.\ud \ud \ud \ud Design\ud \ud Between subjects experimental design.\ud \ud \ud \ud Method\ud \ud Sixty exercisers were randomly assigned to self-affirmation and control groups and completed a structured and anonymous questionnaire about doping intentions and related social cognitive variables.\ud \ud \ud \ud Results\ud \ud Self-affirmed participants reported higher scores in descriptive and moral norms and anticipated regret towards using doping substances, than control participants. Doping intentions were predicted by situational temptation and anticipated regret. Anticipated regret mediated the effect of the self-affirmation manipulation on doping intentions.\ud \ud \ud \ud Conclusions\ud \ud In the context of doping risk communication, self-affirmation may influence the decision-making process by acting on anticipated regret. Our findings can inform risk communication campaigns targeting exercisers who use nutritional supplements.

Heterogeneity in the presentation, antecedents, prognosis and treatment response of antisocial behaviour has long provided a challenge to developmental psychopathology researchers. As illustrated in the incisive Frick and colleagues' Annual Research Review, there is growing evidence that the presence of high callous-unemotional (CU) traits identifies a subgroup of antisocial young people with a particularly aggressive and pervasive form of disorder. Frick and colleagues extend their developmental psychopathology approach to CU traits by linking in theories of conscience development and considering evidence on the stability of CU traits. This commentary addresses these themes and the area more generally, considering (1) comparison of a CU specifier to alternative approaches to antisocial heterogeneity (2) high CU traits in the absence of antisocial behaviour and (3) aspects of the measurement of CU traits.

BACKGROUND: Oppositional defiant disorder(ODD) is considered to be a disorder of childhood, yet evidence suggests that prevalence rates of the disorder are stable into late adolescence and trajectories of symptoms persist into young adulthood. Functional outcomes associated with ODD through childhood and adolescence include conflict within families, poor peer relationships, peer rejection, and academic difficulties. Little examination of functional outcomes in adulthood associated with ODD has been undertaken. METHOD: Data for the present analyses come from a clinic referred sample of 177 boys aged 7-12 followed up annually to age 18 and again at age 24. Annual parental report of psychopathology through adolescence was used to predict self-reported functional outcomes at 24. RESULTS: Controlling for parent reported symptoms of attention deficit hyperactivity disorder (ADHD), Conduct disorder (CD), depression and anxiety, ODD symptoms from childhood through adolescence predicted poorer age 24 functioning with peers, poorer romantic relationships, a poorer paternal relationship, and having nobody who would provide a recommendation for a job. CD symptoms predicted workplace problems, poor maternal relationship, lower academic attainment, and violent injuries. Only parent reported ODD symptoms and child reported CD symptoms predicted a composite of poor adult outcomes. CONCLUSION: Oppositional defiant disorder is a disorder that significantly interferes with functioning, particularly in social or interpersonal relationships. The persistence of impairment associated with ODD into young adulthood calls for a reconsideration of ODD as a disorder limited to childhood. Language: en

There is a growing recognition that the antecedents of risky driving attitudes can be traced to the pre-driving period. Few measures of driving-specific risk taking aimed at pre-drivers (defined here as those who are not permitted to drive independently) have been validated, however, meaning our understanding of the development of risky driving attitudes is limited. This paper reports the construction of a self-report Violation Willingness Scale (VWS) for pre-drivers, examination of the existing Attitudes to Driving Violations Scale (ADVS) in pre-drivers and some preliminary data on the development of propensity to risky driving. Study One found that the VWS and ADVS had strong psychometric properties in a sample of pre-drivers aged 16–19 years of age. Study Two found the VWS and ADVS showed moderate to strong and somewhat independent relationships with a number of existing measures of risky driving behaviour in a sample of fully licensed drivers (age range 18–65 years). This evidence supports the ADVS and VWS as valid tools to measure the propensity to risky driving in pre-drivers. We also discuss preliminary evidence on the relationship between propensity to risky driving and stage of driver training and experience, which indicates that willingness to commit most violations diminishes with driving experience while attitudes and willingness to speed become riskier.\ud \ud

BACKGROUND: Temperamental characteristics emerge early in life and can shape children's development, adjustment and behaviour. We aimed to investigate the association between early infant temperament and later childhood psychiatric disorder in a community sample. METHODS: This prospective, population-based study used data from the Avon Longitudinal Study of Parents and Children (ALSPAC). In a sample of 7318 children, we investigated whether temperamental characteristics assessed at the ages of 6 months and 24 months are associated with an independent diagnosis of psychiatric disorder ascertained at age 7 years. RESULTS: After adjusting for confounders, temperamental characteristics assessed at 6 and 24 months of age were associated with psychiatric disorder at age 7 years. In particular, intensity of emotional reaction at age 6 months was associated with later disorder (adjusted odds ratio = 1.56; 95% confidence interval 1.19, 2.04; P = 0.002). These associations were stronger in girls and in those children with high levels of intensity at both 6 and 24 months of age. CONCLUSIONS: Temperamental characteristics involving high levels of emotional intensity within the first year of life are longitudinally associated with psychiatric disorder in mid-childhood, suggesting that the roots of psychiatric disorder may, in some cases, lie very early in life.

background: Sperm banking is recommended for all men diagnosed with cancer where treatment is associated with risk of long-term gonadatoxicity, to offer the opportunity of fatherhood and improved quality of life. However, uptake of sperm banking is lower than expected and little is known about why men refuse. Our aims were to determine: (i) demographic and medical variables associated with decisions about banking and (ii) differences in quality of life between bankers and non-bankers at diagnosis (Time 1 (T1)) and 1 year later (Time 2 (T2)).\ud methods: Questionnaires were completed by 91 men (response rate=86.67%) at T1 and 78 (85.71% response rate) at T2.\ud results: In all, 44 (56.41%) banked sperm. They were younger and less likely to have children than non-bankers. In a subset of men who were not sure if they wanted children in the future (n=36), 24 banked sperm. Among this group, those who banked were younger, more satisfied with clinic appointments and less worried about the health of future children. At T2, there were no differences in quality of life between bankers and non-bankers.\ud conclusion: For those who are uncertain about future reproductive plans, decisions depend on their health on diagnosis and satisfaction with clinic care. We conclude that extra care should be taken in counselling younger men who may have given little consideration to future parenting. Results support previous findings that the role of the doctor is vital in facilitating decisions, especially for those who are undecided about whether they wanted children in the future or not.

Three subdimensions of ODD symptoms have been proposed -angry/irritable (IR), argumentative/defiant (DF) and antagonism (AN). This study tested whether longitudinal symptom trajectories could be identified by these subdimensions. Group-based trajectory analysis was used to identify developmental trajectories of IR, DF and AN symptoms. Multi-group trajectory analysis was then used to identify how subdimension trajectories were linked together over time. Data were drawn from the Pittsburgh Girls Study (PGS; N = 2450), an urban community sample of girls between the ages of five--eight at baseline. We included five waves of annual data across ages five-13 to model trajectories. Three trajectories were identified for each ODD subdimension: DF and AN were characterized by high, medium and low severity groups; IR was characterized by low, medium stable, and high increasing groups. Multi-trajectory analysis confirmed these subdimensions were best linked together based on symptom severity. We did not identify girls' trajectory groups that were characterized predominantly by a particular subdimension of ODD symptoms. Membership in more severe symptom groups was significantly associated with worse outcomes five years later. In childhood and early adolescence girls with high levels of ODD symptoms can be identified, and these youth are characterized by a persistently elevated profile of IR, DF and AN symptoms. Further studies in clinical samples are required to examine the ICD-10 proposal that ODD with irritability is a distinct or more severe form of ODD.

This paper, describes shortcomings of prescriptive regimes and the emergence of and progressive internationalisation of what is variously described as a goal setting or risk-based approach. Specifically the adoption of the "safety case regime" and how it can be used to improve standards of safety and used as a decision support tool is described. The introduction of a "safety case regime" has taken the industry several years to fully appreciate and effectively apply it as a tool for improving standards of safety. The development of a safety case can provide essential insight into the risks facing an installation and the controls required to manage them. How this information is then used most effectively in operations is still an area for improvement; however there are some key approaches that can provide valuable insight and information to operators on a day to day basis. Historically, most regulatory safety regimes have prescribed rules and standards that must be achieved, with varying degrees of enforcement. The limitations of this approach have been demonstrated in subsequent major accidents following which it was shown that the law was being complied with. A typical response to such incidents was to amend the regulations; often resulting in unnecessary additional costs, and a detailed focus on compliance, rather than understanding the risks associated with an individual facility and how it is operated. The safety case regime was born out the recognition that such mandated regimes were not effective in preventing major accidents. The use of Bowties as an operational risk based decision support tool is considered with both the benefits and potential pitfalls of this approach being described. This paper builds on extensive experience gained in the North Sea and an approach being developed for use offshore Ghana.

The human mirror neuron system is believed to play an important role in facilitating the ability of athletes to anticipate the actions of an opponent. This system is often assessed with EEG by measuring event-related changes in mu (8-13Hz) sensorimotor oscillations. However, traditional channel-based analyses of this measure are flawed in that due to volume conduction effects mu and non-mu alpha activity can become mixed. This flaw means it is unclear the extent to which mu activity indexes the mirror system, as opposed to other processes such as attentional demand. As a solution to this problem, we use independent component analysis to separate out the underlying brain processes during a tennis-related action observation and anticipation task. We investigated expertise-related differences in independent component activity. Experienced tennis players (N=18) were significantly more accurate than unexperienced novices (N=21) on the anticipation task. EEG results found significant group differences in both the mu and beta (15-25Hz) frequency bands in sensorimotor components, with earlier and greater desynchronisation in the experienced tennis players. In particular, only experienced players showed desynchronisation in the high mu (11-13Hz) band. No group differences were found in posterior alpha components. These results show for the first time that expertise differences during action observation and anticipation are unique to sensorimotor sources, and that no expertise-related differences exist in attention modulated, posterior alpha sources. As such, this paper provides a much cleaner measure of the human mirror system during action observation, and its modulation by motor expertise, than has been possible in previous work.

Novice motorists are at high crash risk during the first few months of driving. Risky behaviours such as speeding and driving while distracted are well-documented contributors to crash risk during this period. To reduce this public health burden, effective road safety interventions need to target the pre-driving period. We use the Theory of Planned Behaviour (TPB) to identify the pre-driver beliefs underlying intentions to drive over the speed limit (N = 77), and while over the legal alcohol limit (N = 72), talking on a hand-held mobile phone (N = 77) and feeling very tired (N = 68). The TPB explained between 41% and 69% of the variance in intentions to perform these behaviours. Attitudes were strong predictors of intentions for all behaviours. Subjective norms and perceived behavioural control were significant, though weaker, independent predictors of speeding and mobile phone use. Behavioural beliefs underlying these attitudes could be separated into those reflecting perceived disadvantages (e.g., speeding increases my risk of crash) and advantages (e.g., speeding gives me a thrill). Interventions that can make these beliefs safer in pre-drivers may reduce crash risk once independent driving has begun.

Introduction Given poor survival rates for lung cancer, health-related quality of life (HRQoL) is very important. Smoking is prevalent among those diagnosed with lung cancer, and continued smoking is associated with compromised HRQoL in other patient groups. Aims A systematic review was conducted to determine: (i) differences in HRQoL between lung cancer patients who smoke compared with those who quit or never smoked and (ii) changes in HRQoL in patients who continue to smoke after diagnosis compared with those who quit or never smoked. Method Scopus, Medline, PubMed, PsychINFO and Web of Knowledge from January 1995 to June 2010 were searched. The included studies were assessed and given a score for quality. Results Eight studies met the inclusion criteria. Four studies showed that lung cancer patients who smoked report impaired HRQoL compared with those who never smoked or had quit. Smokers reported significantly lower HRQoL than former smokers, who in turn reported lower HRQoL than never smokers. This finding remained consistent over time. Conclusions When taking account of methodological quality, smoking is associated with poorer HRQoL in lung cancer patients. These results suggest that programmes are needed to address the specific support needs of this group and promote HRQoL during their final months. Longitudinal research is necessary to further understand the association between smoking and HRQoL.

Study question: What medical and psychological variables predict why men with banked sperm do not return for semen analysis after their cancer treatment has ended? Summary answer: Men who decline the offer of semen analysis are less likely to have reported adverse side effects during cancer treatment, and have a more negative experience of banking sperm and a more negative attitude towards disposal of their stored semen than those who attend. What is known already?: Previous authors have noted that male cancer survivors seem reluctant to have their fertility tested after their treatment has ended. Moreover, the utilization rates of banked sperm are very low (,10%) and the majority of samples are kept for many years without being used. Study design, size and duration: A cross-sectional study of 499 cancer survivors who were sent a questionnaire about their views on sperm banking, fertility and post-treatment semen analysis between April 2008 and December 2010. participants and setting: Men (aged 18–55 years) who had banked sperm in Sheffield and Nottingham (UK) prior to gonadotoxic treatment for cancer more than 5 years previously. Main results and the role of chance: Completed questionnaires were received from 193 men (38.7% response rate) whose samples had been banked for 9.18+3.70 years (range = 4.94–26.21) and whose current age was 35.08+7.08 years (range = 21.58–54.34; mean+SD). One-third (35.8%) had never attended for semen analysis. In multivariate analysis, the odds of not attending for semen analysis were significantly greater among men who did not experience adverse treatment side effects [odds ratio (OR) = 5.72, 95% confidence interval (CI) = 2.10–15.56], who reported a more negative experience of banking sperm (OR = 1.82, 95% CI = 1.17– 2.82) and a more negative attitude to disposal of their stored semen (OR = 1.56, 95% CI ¼ 1.01–2.42). Limitations and reasons for caution: Only 38.7% of those eligible agreed to take part. We do not know the characteristics of men who declined to take part, if they agreed to attend semen analysis without completing the questionnaire or whether they had chosen to have semen analysis performed elsewhere (e.g. private sector). Some of the measures used (e.g. experience of banking sperm) relied on men’s recall of events many years previously. Wider implications of the findings: New strategies are required to encourage these men to engage with fertility monitoring programmes if sperm banks are to be used cost-effectively and men are to be given appropriate fertility advice. Study funding and competing interests: This paper was supported by funding from Cancer Research-UK to C.E., A.A.P. and R.R. (C481/A8141). The views expressed are those of the authors. No competing interests declared.

Objectives: Little is known about the aetiology of the links between sleep disturbance and anxiety and depression symptoms. The aim of this study was to estimate genetic and environmental influences on these associations. Methods: Questionnaires were completed by 1556 young adults from twin and sibling pairs (61.5% female). Results: Sleep disturbance was moderately correlated with symptoms of anxiety (r=.39) and depression (r=.50). There was substantial overlap between genes influencing sleep disturbance and those influencing symptoms of anxiety (rA=.58) and depression (rA=.68). Overall, the associations between sleep and symptoms of both anxiety and depression were mainly due to genes (explaining 74% and 58% of the covariances respectively), with the remainder due to nonshared environmental factors. Conclusions: Moderate phenotypic and genetic correlations between the phenotypes support the view that sleep disturbance is related to the presence of various psychiatric difficulties, but also warrants independent consideration and treatment.

Multivariate genetic studies have revealed genetic correlations between antisocial behavior (ASB) and substance use (SU). However, ASB is heterogeneous, and it remains unclear whether all forms are similarly related to SU. The present study examines links between cannabis use, alcohol consumption, and aggressive and delinquent forms of ASB using a behavioral genetic approach. Participants were 1,688 adolescents (482 monozygotic twins, 852 dizygotic twins, and 354 nontwin siblings) aged 15–23 years old (M = 16.91), sampled from the community in the U.K. Multivariate model fitting revealed that the genetic components of alcohol consumption and cannabis use correlated with those of both aggression (.21 and .49, respectively) and delinquency (.35 and .69, respectively). Results suggest that both aggression and delinquency have genetic effects in common with alcohol consumption and cannabis use.

The effects of self-affirmation manipulations are not yet well understood because several different affirmation manipulations have been tested using multiple dependent variables. The aim of the present research was to establish whether global self-feelings and self-esteem, or interpersonal positive feelings are affected by affirming the self. Experiment 1 showed that completing a kindness questionnaire led to adolescent girls reporting more positive interpersonal feelings, but no greater self-feelings or self-esteem than completing an opinions (control) questionnaire. Experiment 2 showed again that self-affirmation did not affect self-esteem, and that there were few differences between writing an essay about a cherished value, writing an essay about kindness, or completing a questionnaire about kindness in boosting positive interpersonal feelings. The findings are discussed in relation to self-affirmation theory and the possible practical implications of self-affirmation for aiding the delivery of social and health messages.

BackgroundCertain aspects of sleep co-occur with externalizing behaviours in youth, yet little is known about these associations in adults. The present study: (1) examines the associations between diurnal preference (morningness versus eveningness), sleep quality and externalizing behaviours; (2) explores the extent to which genetic and environmental influences are shared between or are unique to these phenotypes; (3) examines the extent to which genetic and environmental influences account for these associations.MethodQuestionnaires assessing diurnal preference, sleep quality and externalizing behaviours were completed by 1556 young adult twins and siblings.ResultsA preference for eveningness and poor sleep quality were associated with greater externalizing symptoms [r=0.28 (95% CI 0.23–0.33) and 0.34 (95% CI 0.28–0.39), respectively]. A total of 18% of the genetic influences on externalizing behaviours were shared with diurnal preference and sleep quality and an additional 14% were shared with sleep quality alone. Non-shared environmental influences common to the phenotypes were small (2%). The association between diurnal preference and externalizing behaviours was mostly explained by genetic influences [additive genetic influence (A)=80% (95% CI 0.56–1.01)], as was the association between sleep quality and externalizing behaviours [A=81% (95% CI 0.62–0.99)]. Non-shared environmental (E) influences accounted for the remaining variance for both associations [E=20% (95% CI −0.01 to 0.44) and 19% (95% CI 0.01–0.38), respectively].ConclusionsA preference for eveningness and poor sleep quality are moderately associated with externalizing behaviours in young adults. There is a moderate amount of shared genetic influences between the phenotypes and genetic influences account for a large proportion of the association between sleep and externalizing behaviours. Further research could focus on identifying specific genetic polymorphisms common to both sleep and externalizing behaviours.

Background: Callous and unemotional (CU) traits might usefully subtype DSM‐IV conduct disorder (CD). We investigate this hypothesis in a large, nationally representative sample of 5–16‐year‐olds. We also examine the characteristics of children with high CU traits but without CD. Methods: Data come from the 2004 British Child and Adolescent Mental Health Survey including 7,977 children, 5,326 of whom were followed up after 3 years. DSM‐IV diagnoses of psychiatric disorder were based on parent, teacher and child report. CU traits were assessed by parent report. Results: Of the 2% of the sample who were diagnosed with DSM‐IV CD, 46.1% were high on CU traits. In addition, 2.9% of the sample were high on CU traits without CD. Children with CD and CU traits showed more severe behavioural disturbance and were at substantially higher risk of CD diagnosis 3 years later. Children high on CU traits without CD showed evidence of disturbed functioning. Conclusions: Subtyping CD using CU traits identifies children with more severe and persistent psychopathology. Children with high CU traits but no CD diagnosis require further investigation.

Objective Callous-unemotional (CU) traits in children and adolescents are increasingly recognized as a distinctive dimension of prognostic importance in clinical samples. Nevertheless, comparatively little is known about the longitudinal effects of these personality traits on the mental health of young people from the general population. Using a large representative sample of children and adolescents living in Great Britain, we set out to examine the effects of CU traits on a range of mental health outcomes measured 3 years after the initial assessment. Method Parents were interviewed to determine the presence of CU traits in a representative sample of 7,636 children and adolescents. The parents also completed the Strengths and Difficulties Questionnaire, a broad measure of childhood psychopathology. Three years later, parents repeated the Strengths and Difficulties Questionnaire. Results At 3-year follow-up, CU traits were associated with conduct, hyperactivity, emotional, and total symptom scores. After adjusting for the effects of all covariates, including baseline symptom score, CU traits remained robustly associated with the overall levels of conduct problems and emotional problems and with total psychiatric difficulties at 3-year follow-up. Conclusions Callous-unemotional traits are independently associated with future psychiatric difficulties in children and adolescents. An assessment of CU traits adds small but significant improvements to the prediction of future psychopathology. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(11):1079–1084.

Skilled performers interpret cues in the preparatory movements of their opponents to anticipate future events in many sports. Little work has tested whether these cues can be disguised. Using a temporal occlusion paradigm, this paper examines the effect of disguise on an Australian sample of expert (16 male, 2 female, age M = 24.67, SD = 9.47 years) and novice players’ (24 male, 38 female, age M = 22.26, SD = 5.24 years) anticipation of tennis ground strokes. Analysis of variance (ANOVA) showed that expert anticipation was more accurate than novice overall (p < .001), and disguise reduced accuracy (p = .001). The disguise effect differed by expertise across occlusion points (p = .027). The experts’ anticipatory advantage was removed by disguise at 40 ms before contact. Novice performance was significantly below chance for disguise shots occluded at contact. These results indicate that disguise is an important topic for research and practice.

Background: Antisocial behaviour is often comorbid with depressed mood but is itself a collection of heterogeneous behaviours. Using a genetically informative design, we examine heterogeneity in anti- social behaviour and overlaps between different forms of antisocial behaviour with depressed mood. Methods: Data were drawn from the G1219 large-scale community sample containing self-report questionnaire data from 941 twin pairs and 328 sibling-pairs aged 12–21 years. Results: Inter-correlations among oppositionality, physical aggression and delinquency, and between the antisocial subscales and depressed mood, were mediated by genetic and non-shared environmental influences. Genetic factors generally contributed more to the correlations than the non- shared environment. Conclusions: These results indicate that many genetic and non-shared envir- onmental influences were common to all the traits studied, but there was also evidence for trait-specific effects. Keywords: Conduct disorder, aggression, delinquency, oppositionality, depression, twin.

A number of studies indicate that fast music influences performance in everyday activities including shopping and gambling, but the mechanisms through which this effect is realised are not well understood. This study investigates whether fast tempo music influences gambling via an effect on arousal using a laboratory virtual roulette task. One hundred and forty-four participants played virtual roulette whilst listening to fast tempo, slow tempo or no music. Music tempo alone did not influence betting speed, expenditure or risk-taking. Furthermore tempo did not influence participants’ physiological or subjective arousal levels, nor participants’ opinions of the musical stimuli in terms of liking, familiarity, fit or its ability to aid concentration. Our findings suggest that there are some circumstances under which the effect of music tempo does not operate and therefore provides an insight into the limits of music tempo as an explanation for music effects on behaviour. This study has implications for the way that musical characteristics are operationalised in future research into music’s effects on behaviour.

Increased anxiety and depression symptoms have been reported in individuals with neurodevelopmental disorders, and have been found to be associated with motor coordination difficulties, but little is known about the aetiology of these associations. This study aimed to assess genetic, shared (making twins/siblings alike) and non-shared (individual-specific) environmental influences on the association between poor coordination and symptoms of anxiety and depressed mood using a sample of adult twin and sibling pairs. Participants were asked about their coordination skill and anxiety and depression symptoms. About half of the variance in coordination difficulty was explained by familial (combined genetic and shared environmental) influences, with the remaining variance explained by non-shared environmental influences. Phenotypic associations between coordination and anxiety (r=.46) and depression symptoms (r=.44) were largely underpinned by shared familial liability for the three traits. Non-shared environment accounted for about a third of the phenotypic association. Results suggest that both familial and non-shared environmental influences play a role in the aetiology of coordination difficulty and its association with internalizing symptoms. The current study highlights that both biological and environmental pathways shared between these symptoms should be examined in future research to inform prevention and treatment approaches in clinical settings.

Objective: The infratemporal fossa (ITF) is a continuation of the temporal fossa between the internal surface of the zygoma and the external surface of the temporal bone and greater wing of the sphenoid bone that is sitting deep to the ramus of the mandible. The principal structure to understanding its relationships is the lateral pterygoid muscle. Other important structures are the medial pterygoid muscle, the maxillary artery, the pterygoid venous plexus, the otic ganglion, the chorda tympani nerve and the mandibular nerve. In this study, we describe the microsurgical anatomy of the ITF, as viewed by step-by-step anatomical dissection and also through the perspective of three lateral approaches and one anterior surgical approach. Methods: Eight cadaver specimens were dissected. In one side of all specimens, an anatomical dissection was done in which a wide preauricular incision from the neck on the anterior border of the sternoclidomastoid muscle at the level of the cricoid cartilage to the superior temporal line was made. The flap was displaced anteriorly and the structures of the neck were dissected followed by a zygomatic osteotomy and dissection of the ITF structures. On the other side were the surgical approaches to the ITF. The combined infratemporal and posterior fossa approach was done in two specimens, the subtemporal preauricular infratemporal fossa approach in two, the zygomatic approach in two, and the lateral transantral maxillotomy in two. The anatomical dissections were documented on the three-dimensional (3D) anaglyphic method to produce stereoscopic prints. Results: The lateral pterygoid muscle is one of the principal structures to enable understanding of the relationships into the ITF. The tendon of the temporal muscle inserts in the coronoid process at the ITF. The maxillary artery is the terminal branch of the external carotid artery that originates at the neck of the mandible and runs into the parotid gland. In our dissections the maxillary artery was lateral to the buccal, lingual, and inferior alveolar nerves. We found the second part of the maxillary artery superficial to the lateral pterygoid muscle in all specimens The anterior and posterior branches of the deep temporal artery supply the temporal muscle. In two cases we found a middle deep temporal artery. The different approaches that we used provided different views of the same anatomical landmarks and this provides not only safer surgery but also the best choice to approach the ITF according with the pathology extension. Conclusions: The ITF is a complex region on the skull base that is affected by benign and malignant tumors. The study through different routes is helpful to disclose the relationship among the anatomical structures. Although the authors have shown four approaches, there are a variety of approaches and even a combination of these can be used. This type of anatomical knowledge is essential to choosing the best approach to treat lesions in this area.

Background: Growing evidence indicates a link between unintentional injury and both disruptive and emotional psychopathology. We present further evidence of these associations and address the underlying mechanisms. We also examine the genetic contribution to unintentional injury. Methods: The Virginia Twin Study of Adolescent Behavioral Development provides genetically informative multi-wave and multi-informant data regarding common psychopathology using the Child and Adolescent Psychiatric Assessment interview. The EASI temperament scales and child injury involvement were measured in parent-report questionnaires. Results: Unintentional injury showed significant genetic effects in girls and significant shared environmental effects in boys and girls. Symptoms of over-anxious disorder (OAD), and the EASI temperament scales were independently associated with injury. Longitudinal modeling showed impulsivity and OAD symptoms were related prospectively to injury involvement. Injuries did not increase risk for later impulsivity or OAD symptoms but were related prospectively to separation anxiety disorder symptoms. Conclusions: Impulsivity and OAD symptoms increased risk of later injury. We discuss the processes that may be involved in these relationships.

BackgroundLow income is a widely studied risk factor for child and adolescent behavioural difficulties. Previous research on this relationship has produced mixed findings.AimsTo investigate the level, shape and homogeneity of income gradients in different types of antisocial behaviour.MethodA representative sample of 7977 British children and adolescents, aged 5–16 years, was analysed. Hypotheses concerning the shapes and homogeneity of the relationships between family socioeconomic status and multiple antisocial behaviour outcomes, including clinical diagnoses of oppositional-defiant disorder, conduct disorder and symptom subscales, such as irritability and hurtfulness, were tested by structural equation models.ResultsConsistent income gradients were demonstrated across all antisocial behaviours studied. Disorder prevalence and mean symptom counts decreased across income quintiles in a non-linear fashion.ConclusionsOur findings emphasise that income gradients are similar across different forms of antisocial behaviour and indicate that income may lead to greater behavioural differences in the mid-income range and less variation at low- and high-income extremes.

Identifying the changes in driving behavior that underlie the decrease in crash risk over the first few months of driving is key to efforts to reduce injury and fatality risk in novice drivers. This study represented a secondary data analysis of 1148 drivers who participated in the UK Cohort II study. The Driver Behavior Questionnaire was completed at 6 months and 1, 2 and 3 years after licensure. Linear latent growth models indicated significant increases across development in all four dimensions of aberrant driving behavior under scrutiny: aggressive violations, ordinary violations, errors and slips. Unconditional and conditional latent growth class analyses showed that the observed heterogeneity in individual trajectories was explained by the presence of multiple homogeneous groups of drivers, each exhibiting specific trajectories of aberrant driver behavior. Initial levels of aberrant driver behavior were important in identifying sub-groups of drivers. All classes showed positive slopes; there was no evidence of a group of drivers whose aberrant behavior decreased over time that might explain the decrease in crash involvement observed over this period. Male gender and younger age predicted membership of trajectories with higher levels of aberrant behavior. These findings highlight the importance of early intervention for improving road safety. We discuss the implications of our findings for understanding the behavioral underpinnings of the decrease in crash involvement observed in the early months of driving.

The trigone of the lateral ventricle is challenging to reach. Tumors that typically occur in this area include ependymomas, subependymomas, neurocytomas, oligodendrogliomas, meningiomas, and choroid plexus papillomas. Bounded by eloquent brain and critical arterial and venous anatomy, the trigone requires an understanding of the surrounding anatomy and its functional relationship to organized thought.

OBJECTIVE— Glycemic control using inhaled, dry-powder insulin plus a single injection of long-acting insulin was compared with a conventional regimen in patients with type 2 diabetes, which was previously managed with at least two daily insulin injections. RESEARCH DESIGN AND METHODS— Patients were randomized to 6 months’ treatment with either premeal inhaled insulin plus a bedtime dose of Ultralente (n = 149) or at least two daily injections of subcutaneous insulin (mixed regular/NPH insulin; n = 150). The primary efficacy end point was the change in HbA1c from baseline to the end of study. RESULTS— HbA1c decreased similarly in the inhaled (−0.7%) and subcutaneous (−0.6%) insulin groups (adjusted treatment group difference: −0.07%, 95% CI −0.32 to 0.17). HbA1c CONCLUSIONS— Inhaled insulin appears to be effective, well tolerated, and well accepted in patients with type 2 diabetes and provides glycemic control comparable to a conventional subcutaneous regimen.

Background: Studies linking testosterone and antisocial behavior in humans have produced mixed results. Adolescence offers a promising period to study this relationship; circulating testosterone increases dramatically in boys during puberty, and antisocial behavior increases during the same period. Methods: Our analyses were based on boys aged 9 –15 years who were interviewed during the first three waves of the Great Smoky Mountains Study. Measures included interview assessment of DSM-IV conduct disorder (CD) symptoms and diagnosis, blood spot measurement of testosterone, Tanner staging of pubertal development, and assessment of leadership behaviors and peer deviance. Results: The adolescent rise in CD was primarily attributable to an increase in nonphysically aggressive behaviors. Increasing levels of circulating testosterone and association with deviant peers contributed to these age trends. There was no evidence that physical aggression was related to high testosterone. Evidence of biosocial interactions was identified; testosterone was related to nonaggressive CD symptoms in boys with deviant peers and to leadership in boys with nondeviant peers. Conclusions: The results are consistent with the hypothesis that testosterone relates to social dominance, with the assumption that behaviors associated with dominance differ according to social context.

Although reading difficulties show well-established overlaps with disruptive behavior disorders in childhood, much less is known about reading-disabled children's vulnerability to emotional difficulties. Using longitudinal data from 6 assessments of boys in the Pittsburgh Youth Study, we found robust links between severe, persistent reading problems and increased risk for depressed mood in a community sample of boys aged 7 and 10 years at initial assessment, though not in those who had already entered their teens. These associations could not be accounted for in terms of selected family risks or comorbid disruptive behaviors; instead, the pattern of the findings pointed to the existence of more direct causal processes whereby reading problems influence younger boys' risk of depressed mood.

Mood regulation problems are a common source of concern for clinicians, parents and young people alike. Some forms of mood dysregulation - in particular, perhaps, those involving depressed and elated mood - have received extensive research attention across the years. By contrast, there is vanishingly little research on irritable mood, anger and touchiness, even though these problems are among the most prominent that any clinician is likely to encounter. The aim of this Special Issue (SI) is to help build an evidence base on mood regulation problems of this kind, and to stimulate further research in the field. The guest editors of the SI are extremely grateful to the contributing authors, who responded with enthusiasm to the invitation for contributions addressing this key issue in psychopathology. Each article went through JCPP's standard rigorous process of external review. The contributions are important not least because they challenge a number of long-held views, highlight the clinical relevance of mood regulation problems, and identify areas where there is a pressing need for further research. We hope that the SI will provide clinicians (who often feel ill-equipped to deal with such forms of mood dysregulation), with some practically translatable knowledge. We also hope it will offer researchers a framework for approaching outstanding questions about aetiology, and for exploring the mechanisms that underlie the problems many children and young people face in regulating their moods.

BACKGROUND: The Strengths and Difficulties Questionnaire (SDQ) is widely used to screen for child mental health problems and measure common forms of psychopathology in 4- to 16-year-olds. Using longitudinal data, we examined the validity of a version adapted for 3- to 4-year-olds. METHODS: We used SDQ data from 16 659 families collected by the Millennium Cohort Study, which charts the development of children born throughout the United Kingdom during 2000–2001. Parents completed the preschool SDQ when children were aged 3 and the standard SDQ at ages 5 and 7. The SDQ’s internal factor structure was assessed by using confirmatory factor analysis, with a series of competing models and extensions used to determine construct, convergent, and discriminant validity and measurement invariance over time. Predictive validity was evaluated by examining the relationships of age 3 SDQ scores with age 5 diagnostic measures of attention-deficit/hyperactivity disorder, autism spectrum disorder/Asperger syndrome, and teacher-reported measures of personal, social, and emotional development. RESULTS: Confirmatory factor analysis supported a 5-factor measurement model. Internal reliability of subscales ranged from ω = 0.66 (peer problems) to ω = 0.83 (hyperactivity). Item-factor structures revealed measurement invariance over time. Strong positive correlations between ages 3 and 5 SDQ scores were not significantly different from correlations between age 5 and 7 scores. Conduct problems and hyperactivity subscales independently predicted developmental and clinical outcomes 2 years later. CONCLUSIONS: Satisfactory psychometric properties of the adapted preschool version affirm its utility as a screening tool to identify 3- to 4-year-olds with emotional and behavioral difficulties.

Background: This paper addresses bulimia symptoms in a large community sample of twins aged 8 to 17 years. We aim to identify environmental correlates of bulimia symptoms and relationships with other psychiatric disorder symptoms. The twin design allows examination of the structure of genetic and environmental effects. Methods: DSM-IIIR bulimia symptoms and consequential impairment were measured by interview in the first wave of the Virginia Twin Study of Adolescent Behavioral Development. Comorbidity with other psychiatric symptoms and environmental correlates were examined and the relative contributions of genes and environment were assessed using structural equation modeling. Results: An item-response theory model indicated that the range of bulimic symptoms represented a single underlying trait. Bulimia symptoms were more common in postmenarche girls and positively associated with body-mass index. Subdiagnostic symptomatology was associated with impairment in psychosocial functioning. Bulimia symptoms were strongly associated with other psychiatric disorders symptoms including anxiety and depression. Genetic model fitting identified strong additive genetic effects on the symptom score. Accounting for a potential violation of the equal environment assumption for identical and fraternal twins slightly reduced estimated genetic variance. Conclusions: The pattern of comorbidity suggests overlap between bulimia symptoms and those of internalizing disorders. Substantial genetic variance (44%) was evident in the most conservative model.

The importance of irritability as measured among the symptoms of oppositional defiant disorder (ODD) has dramatically come to the fore in recent years. New diagnostic categories rely on the distinct clinical utility of irritability, and models of psychopathology suggest it plays a key role in explaining developmental pathways within and between disorders into adulthood. However, only a few studies have tested multidimensional models of ODD, and the results have been conflicting. Further, consensus has not been reached regarding which symptoms best identify irritability. The present analyses use data from five large community data sets with five different measures of parent-reported ODD, comprising 16,280 youth in total, to help resolve these questions. Across the samples, ages ranged from 5 to 18, and included both boys and girls. Confirmatory factor analyses demonstrated that a modified bifactor model showed the best fit in each of the five data sets. The structure of the model included two correlated specific factors (irritability and oppositional behavior) in addition to a general ODD factor. In four of the five models, the best fit was obtained using the items of being touchy, angry and often losing temper as indicators of irritability. Given the structure of the models and the generally high correlation between the specific dimensions, the results suggest that irritability may not be sufficiently distinct from oppositional behavior to support an entirely independent diagnosis. Rather, irritability may be better understood as a dimension of psychopathology that can be distinguished within ODD, and which may be related to particular forms of psychopathology apart from ODD.

Current policy in the UK recommends that men bank sperm prior to cancer treatment, but very few return to use it for reproductive purposes or agree to elective disposal even when their fertility recovers and their families are complete. We assessed the demographic, medical and psychological variables that influence the decision to dispose by contacting men (n = 499) who banked sperm more than five years previously, and asked them to complete questionnaires about their views on sperm banking, fertility and disposal. From 193 responses (38.7% response rate), 19 men (9.8%) requested disposal within four months of completing the questionnaire. Compared with men who wanted their sperm to remain in storage, they were significantly more confident that their fertility had recovered (OR = 1.78, 95% CI = 1.05-3.03, p = 0.034), saw fertility monitoring (semen analysis) as less important (OR = 0.61, 95% CI = 0.39-0.94, p = 0.026), held more positive attitudes to disposal (OR = 5.71, 95% CI = 2.89-11.27, p < 0.001), were more likely to have experienced adverse treatment side-effects (OR = 4.37, CI = 1.61-11.85, p = 0.004) and had less desire for children in the future (OR = 0.41, 95% CI = 0.26-0.64, p < 0.001). Information about men's reasons to dispose of banked sperm may be helpful in devising new strategies to encourage men to engage with sperm banking clinics and make timely decisions about the fate of their samples.

The Driver Behavior Questionnaire (DBQ) is a self-report measure of driving behavior that has been widely used over more than 20 years. Despite this wealth of evidence a number of questions remain, including understanding the correlation between its violations and errors sub-components, identifying how these components are related to crash involvement, and testing whether a DBQ based on a reduced number of items can be effective. We address these issues using a bifactor modeling approach to data drawn from the UK Cohort II longitudinal study of novice drivers. This dataset provides observations on 12,012 drivers with DBQ data collected at .5, 1, 2 and 3 years after passing their test. A bifactor model, including a general factor onto which all items loaded, and specific factors for ordinary violations, aggressive violations, slips and errors fitted the data better than correlated factors and second-order factor structures. A model based on only 12 items replicated this structure and produced factor scores that were highly correlated with the full model. The ordinary violations and general factor were significant independent predictors of crash involvement at 6 months after starting independent driving. The discussion considers the role of the general and specific factors in crash involvement.

Long-term storage of banked sperm, especially when it is not needed, for reproductive purposes, is costly and poses practical problems for sperm banks. For sperm banks to function efficiently, men must understand the implications of unnecessary storage, and make timely decisions about disposal of their own samples. Men who bank sperm prior to cancer treatment are routinely offered follow-up consultations to test their fertility, update consent and, where necessary, expedite referral for Assisted Conception. Yet sperm banks report that men do not respond to letters, suggesting samples are stored needlessly. We conducted semi-structured interviews with six men with a history of not responding to letters, to document reasons for non-response. Interviews were transcribed and analysed using Interpretive Phenomenological Analysis. Men's reasons for not responding are a complex interplay between past, present and future perspectives. In terms of their past, information is important on diagnosis, because men must understand that fertility can change after treatment. Present and future concerns focus on fears of being told fertility has not recovered and being pressured to dispose of banked sperm. The challenge is to devise invitation letters that address men's concerns while offering them tangible benefits and peace of mind.

Objective: Alcohol consumption in adolescence is associated with problem drinking in later life, and there is a need to develop evidence-based interventions to reduce adolescent alcohol consumption. The aims of the present study were to test the ability of a very brief intervention based on self-affirmation theory to reduce alcohol consumption in a sample of adolescents and to examine potential mediators of the effects. Method: 67 adolescents were randomly allocated either to form a self-affirming implementation intention or to complete a distractor task. All participants were exposed to a threatening message concerning the health risks of alcohol consumption. The main outcome measure was subsequent alcohol intake, but message processing (operationalized as perceived threat and message derogation), behavioral intention, and self-efficacy were also measured as potential mediators. Results: The intervention produced a significant decrease in alcohol consumption: Participants in the self-affirming implementation intention condition consumed 2.48 fewer grams of pure alcohol per day at the end of the study than adolescents who completed the distractor task. The effect was not mediated by perceived threat, message derogation, behavioral intention, or self-efficacy. Conclusions: The findings provide support for the efficacy of the self-affirming implementation intention for promoting health behavior change and extend previous research by testing an adolescent sample and observing longer term effects. Further research is needed to find out what mediates the effects of self-affirming implementation intentions on health behavior change.

BackgroundRelatively little is known about the relationships between psychiatric symptoms, diagnosis and psychosocial impairment.AimsTo examine these contemporaneous relationships and prognostic significance in a large general population sample.MethodSymptoms of major depression, conduct and oppositional defiant disorders were assessed by interview in two waves of the Virginia Twin Study of Adolescent behavioural Development (2800 children aged 8–16 years).ResultsManychildren below the DSM–III–R diagnostic threshold, especially for depression, had symptom-related impairment, whereas many children reaching the symptom threshold for conduct and oppositional defiant disorders were little impaired. Impairment score was linearly related to symptom count, with no evidence of any additional impairment at the diagnostic threshold. For depression, only symptoms predicted later symptoms and diagnosis. For conduct and oppositional defiant disorders, impairment was additionally predictive of later symptoms and diagnosis.ConclusionsImpairment, in addition to symptoms, is important for both nosology and prognosis.

Context and objectives: Good clinical teaching is central to medical education but there is concern about maintaining this in contemporary, pressured health care environments. This paper aims to demonstrate that good clinical practice is at the heart of good clinical teaching. Methods: Seven roles are used as a framework for analysing good clinical teaching. The roles are medical expert, communicator, collaborator, manager, advocate, scholar and professional. Results: The analysis of clinical teaching and clinical practice demonstrates that they are closely linked. As experts, clinical teachers are involved in research, information retrieval and sharing of knowledge or teaching. Good communication with trainees, patients and colleagues defines teaching excellence. Clinicians can 'teach' collaboration by acting as role models and by encouraging learners to understand the responsibilities of other health professionals. As managers, clinicians can apply their skills to the effective management of learning resources. Similarly skills as advocates at the individual, community and population level can be passed on in educational encounters. The clinicians' responsibilities as scholars are most readily applied to teaching activities. Clinicians have clear roles in taking scholarly approaches to their practice and demonstrating them to others. Conclusion: Good clinical teaching is concerned with providing role models for good practice, making good practice visible and explaining it to trainees. This is the very basis of clinicians as professionals, the seventh role, and should be the foundation for the further development of clinicians as excellent clinical teachers.

Modeling the heterogeneous trajectories along which antisocial behaviordevelops in childhood and adolescence may contribute in important waysto understanding antecedents of offending in adult life. This paperexamines the development of aggressive and non-aggressive conduct problemsin the Great Smoky Mountains Study of Youth, a longitudinal study in thesoutheastern United States. Aggressive and non-aggressive conduct problemsof clinical severity, police contact and arrest, and family andenvironmental correlates were assessed in four annual interviews for789 boys and 630 girls aged 9–13 at first interview. The bestfitting latent class model identified three developmental trajectories:stable low problem levels, stable high problem levels, and declining levelsof conduct problems, for both aggressive and non-aggressive behaviors. Boyswere over-represented in the stable high trajectory class on the aggressivetrajectory, but sex differences in non-aggressive trajectories were lessmarked. The overlap between aggressive and non-aggressive trajectory classeswas quite limited. Both classifications showed strong associations withrisks of police contact and arrest in early adolescence, and with measuresof family adversity. The results are discussed in relation to developmentalmodels of conduct disorder and delinquency.

A retrospective review of 61 cases of airway management for newborn tracheo-oesophageal fistula (TOF)/oesophageal atresia repair is presented. Standard management included induction of general anaesthesia and muscle relaxation before tracheal intubation, rigid bronchoscopy, careful placement of the tracheal tube below the TOF if possible, and occlusion of the fistula with a Fogarty embolectomy catheter in certain high risk cases. Gastrostomy was not routinely performed. Ventilation proceeded without difficulty in 48 cases. Ventilation difficulties were encountered in 13 cases. Eight of the 13 cases had large TOF, and four had other causes of difficult ventilation not related to the fistula. No patient with a small TOF had ventilation problems because of the TOF. Three patients had a large TOF successfully occluded with an embolectomy catheter through the bronchoscope. There were no complications ascribed to this technique. An algorithm is suggested for anaesthetic-surgical airway management in these cases.

Background Lung cancer is the most common cancer and smoking is the principal cause. Due to poor survival rates, symptom palliation and promotion of health-related quality of life (HRQoL) are primary outcomes for lung cancer patients. Given the established relationship between smoking and lung cancer, patients who have smoked may feel stigmatised or guilty after diagnosis, and more pessimistic about their illness and likely outcomes. This may have adverse implications for HRQoL. Objectives We explored HRQoL and support experiences among newly diagnosed patients with advanced lung cancer. Design Semistructured interviews were conducted with nine patients and analysed using interpretative phenomenological analysis. Results Patients described the physical, emotional and social impact of disease on HRQoL. Fear of compromising their immune system and adjusting to new relationship roles had a wide-ranging effect on patients’ HRQoL. Patients acknowledged links between lung cancer and smoking but some continued to smoke. They were sensitive to the opinions of medical staff about smoking especially those who continued to smoke or recently quit. Conclusions We conclude that staff should give clearer advice about the adverse implications of continued smoking. We discuss the potential value of diagnosis as a teachable moment for promoting smoking cessation among patients and family members.

The Genesis 12–19 (G1219) Study is an ongoing longitudinal study of a sample of UK twin pairs, non-twin sibling pairs, and their parents. G1219 was initially designed to examine the role of gene–environment interplay in adolescent depression. However, since then data have continued to be collected from both parents and their offspring into young adulthood. This has allowed for longitudinal analyses of depression and has enabled researchers to investigate multiple phenotypes and to ask questions about intermediate mechanisms. The study has primarily focused on emotional development, particularly depression and anxiety, which have been assessed at multiple levels of analysis (symptoms, cognitions, and relevant environmental experiences). G1219 has also included assessment of a broader range of psychological phenotypes ranging from antisocial behaviors and substance use to sleep difficulties, in addition to multiple aspects of the environment. DNA has also been collected. The first wave of data collection began in the year 1999 and the fifth wave of data collection will be complete before the end of 2012. In this article, we describe the sample, data collection, and measures used. We also summarize some of the key findings to date.

Background Young drivers are at increased crash risk as a result of adopting risky driving styles. The present work examines the development of risky attitudes from pre-driving to fully-qualified driving, focussing on speed related attitudes. Methods Data were drawn from a UK longitudinal study of adolescent behaviour development in the general population (the G1219 study). At baseline (modal age 17 years) there were 1596 participants, only 18% of whom were fully-qualified drivers. At follow-up (modal age 20 years) 64% were fully-qualified drivers. Attitudes to driving violations, particularly speeding, were measured in all participants at both assessments. Self-reported driving violations, also related to speeding, were measured in fully-qualified drivers at follow-up. Results Attitudes became riskier with driver training/experience. Baseline attitudes measured in pre-drivers did not independently predict violations in those that had become fully-qualified drivers at follow-up. The attitudes of learner and fully-qualified drivers at baseline independently predicted violations at follow-up. Conclusions These results indicate that the driver training period offers a promising opportunity for interventions to develop safer driving attitudes.