Clinical evidence in guardianship of older adults is inadequate: findings from a tri-state study.

PURPOSE: This preliminary study compared clinical evaluations for guardianship in three states with varying levels of statutory reform. DESIGN AND METHODS: Case files for 298 cases of adult guardianship were reviewed in Massachusetts, Pennsylvania, and Colorado, three states with varying degrees of statutory reform. The quality and content of the written clinical evidence for guardianship and the hearing outcome were recorded. RESULTS: The quality of the written clinical evidence for guardianship was best in Colorado, the state with the most progressive statutory reform, earning a grade of B in our ratings, and worst in Massachusetts, a state with minimal reform, earning a grade of D - with nearly two thirds of the written evidence illegible. Information on specific functional deficits was frequently missing and conclusory statements were common. Information about the individual's key values and preferences was almost never provided, and individuals were rarely present at the hearing. Limited orders were used for 34% of the cases in Colorado, associated with more complete clinical testimony, but such orders were used in only 1 case in either Massachusetts or Pennsylvania. IMPLICATIONS: In this study, states with progressive statutes that promote functional assessment are associated with increased quality of clinical testimony and use of limited orders. A continuing dialogue between clinical and legal professionals is needed to advance reform in guardianship, and thereby provide for the needs and protect the rights of adults who face guardianship proceedings.

Statutory reform is associated with improved court practice: results of a tri-state comparison.

PURPOSE: This study investigates the impact of statutory reform in adult guardianship on court practice. METHODS: Case files for 298 cases of adult guardianship were reviewed in three states with varying degrees of statutory reform: MA (no reform), PA (major amendments in 1992), and CO (full re-enactment of statute per UGPPA in 2000). Five court practices associated with progressive statutory reform were studied: (1) diversion to less restrictive alternatives; (2) minimal and appropriate use of emergency procedures; (3) presence of the alleged incapacitated person at the hearing; (4) use of functional evaluation; (5) use of limited orders. RESULTS: CO more frequently utilized all five practices, whereas PA used diversion to less restrictive alternatives and less frequent emergency procedures, but not other practices. MA files rarely showed evidence for use of any of these reforms. IMPLICATIONS: Statutory reform may improve court practice. More study of the effects of reform on court practices, and the vulnerable adults served by these courts, is needed.

Expressed emotion and interdependence in White and Latino/Hispanic family members of patients with schizophrenia.

This study examined associations among ethnicity, expressed emotion (EE) and interdependence in a sample of 41 Latino/Hispanic and White family members of patients with schizophrenia. EE was assessed using both the Camberwell Family Interview (CFI) and the Five Minute Speech Sample (FMSS). These measures were found to be highly concordant for rating EE. However, the CFI appears to identify high EE more often than does the FMSS. Whites were designated as high EE significantly more often than were Latinos/Hispanics, regardless of assessment method. Using the interdependence subscale of the Self-Construal Scale, we found a strong trend for Latino/Hispanics to report a more interdependent self-construal than did Whites. However, contrary to expectations, interdependence was not found to mediate the relationship between ethnicity and EE. EE and interdependence may both play a role in the better course of illness observed for patients from traditional cultures. However, these two constructs may relate to patient functioning through different mechanisms.

Assessment of Capacity to Consent to Treatment: Challenges, the "ACCT" Approach, Future Directions.

OBJECTIVE: To review approaches to assessing consent capacity in patients with neurocognitive or neuropsychiatric illness; to summarize the rationale behind our structured interview for consent capacity; and to outline questions for future research. METHOD: After reviewing legal and clinical literature, and empirically comparing three leading consent capacity instruments, we developed the Assessment of Capacity to Consent to Treatment (ACCT) interview and administered it to adults with dementia (n=20), schizophrenia (n=20), and controls (n=19). Capacity ratings by primary care clinicians and experts blind to the patients' status were obtained for a subsample. RESULTS: Interscorer reliability was r=.90; internal consistency reliability was .α=96. ACCT scores agreed 82% of the time (kappa = .44; p<.01) with primary care clinician ratings of capacity and 75% of the time (kappa = .50; p<.05) with expert ratings of capacity. Patients with dementia and schizophrenia could express treatment choices but performed worse than controls on measures of understanding, appreciation as problems with foresight, rational reasoning, and values-based reasoning. Only patients with schizophrenia performed worse on a measure of appreciation as problems with distrust. CONCLUSION: The method of assessing consent capacity described here has adequate reliability and validity, and may provide a useful starting point for clinicians and researchers. Many questions remain about the nature of consent capacity, its component constructs, and the meaning of instrument versus clinician ratings of capacity. Future adaptations, particularly in the assessment of appreciation and reasoning, and additional studies in more diverse samples, are needed.

Ethnicity, expressed emotion, and schizophrenia patients' perceptions of their family members' criticism.

Expressed emotion is a widely researched construct. However, less is known about patients' own perceptions of their relatives' expressed emotion. Using a sample of 42 patient/family member dyads with schizophrenia, we examined the concordance between the number of criticisms expressed by relatives during the Camberwell Family Interview and patients' perceptions of how critical they perceived their relative to be. As predicted, white and Latino family members who expressed more criticism during the Camberwell Family Interview were indeed perceived as more critical by patients. Among blacks, however, no significant association was found between relatives' expressed criticism and patients' perceptions of their relatives' criticism. Findings from this study suggest that cultural/ethnic values may influence how criticism from relatives is perceived and experienced by patients.

Ethnicity, expressed emotion, and communication deviance in family members of patients with schizophrenia.

This study examined the relationships among expressed emotion (EE), communication deviance (CD), and ethnicity in a sample of 57 white, Latino, and black relatives of patients with schizophrenia. A new method of assessing CD from the Five Minute Speech Sample was also developed and evaluated against an existing method (the Camberwell Family Interview; CFI). As hypothesized, high expressed emotion rated (from the CFI) was associated with higher levels of CD, and the Five Minute Speech Sample and CFI methods of assessing CD were concordant. CD statements made by white family members focused most on patient behaviors/symptoms that reflected a lack of independent functioning. CD statements of Latino and black relatives, however, focused most on patient behaviors that interfered with the family's interdependent functioning. Family members may have particular difficulty communicating coherently when discussing patients' inability to uphold important values and behaviors that are sanctioned by their ethnic background.