Eating disorder symptoms among transgender and gender diverse youth.

Compared to cisgender peers, transgender and gender diverse (TGD) youth and adults report elevated eating disorder (ED) symptoms likely related to gender dysphoria and attempts to modify their bodies accordingly. Less is known about the impact on gender-affirming care and ED symptoms. This study aimed to expand on extant research and describe ED symptoms in TGD youth seeking gender-affirming care while exploring potential associations between gender-affirming hormone use and ED symptoms. A total of 251 TGD youth completed the Eating Disorders Examination-Questionnaire (EDE-Q) as part of routine clinical care. ANCOVAs and negative binomial regressions examined differences in ED symptoms among transgender females (identifying as female but assigned male at birth) and transgender males (identifying as male but assigned female at birth). ED severity was not significantly different among transgender females versus transgender males, (p = .09), or associated with gender-affirming hormone use (p = .07). Transgender females receiving gender-affirming hormones reported a greater proportion of objective binge eating episodes compared to those who were not (p = .03). Over a quarter of TGD youth reported engagement in ED behaviors suggesting assessment and intervention related to ED behaviors among TGD youth is imperative since adolescence is a particularly vulnerable period for adolescents and engagement in ED behaviors could lead to full ED development and medical risk.

Modification of an inpatient medical management protocol for pediatric Avoidant/Restrictive Food Intake Disorder: improving the standard of care.

BACKGROUND: No guidelines currently exist that represent a standardization of care for Avoidant/Restrictive Food Intake Disorder (ARFID) on an inpatient service. Unique features of this diagnosis (e.g., sensory sensitivity contributing to involuntary emesis) suggest that established protocols that were developed for anorexia nervosa might be less effective for adolescents with ARFID. To inform improved inpatient medical stabilization and care for these patients, we first provide an overview of clinical characteristics for patients with ARFID who presented to a pediatric hospital for inpatient eating disorder care. We use these descriptives to outline the rationale for, and executions of, modifications to an inpatient protocol designed to flexibly meet the needs of this clinical population. METHODS: Chart review with descriptive statistics were conducted for patients who had received an ARFID diagnosis from March 2019 to March 2023 (N = 32, aged 9-23). We then present a case series (n = 3) of adolescents who either transitioned to a novel adjusted protocol from an original standard of care on the inpatient service, or who received only the standard protocol. RESULTS: The sample was aged M(SD) = 15.6 (3.3) years, 53% male, and a majority (69%) presented with the ARFID presentation specific to fear of negative consequences. On average, patients had deviated from their growth curve for just over two years and presented with mean 76% of their estimated body weight. Of those requiring nasogastric tube insertion during admission (n = 8, 25%), average duration of tube placement was 15 days. From within this sample, case series data suggest that the adjusted protocol will continue to have a positive impact on care trajectory among adolescents admitted for ARFID including improved weight gain, reduction of emesis, and improved food intake. CONCLUSIONS: Findings demonstrate the likely need to tailor established medical inpatient protocols for those with ARFID given different symptom presentation and maintenance factors compared to patients with anorexia nervosa. Further research is warranted to explore the longer-term impact of protocol changes and to inform standardization of care for this high priority clinical population across care sites.

No current standard of care exists for pediatric patients with Avoidant/Restrictive Food Intake Disorder (ARFID) who are hospitalized for medical stabilization related to complications secondary to malnutrition. Clinical features of this diagnosis (e.g., sensory sensitivity) suggest that existing treatment protocols developed for patients with other restrictive eating disorders, like anorexia nervosa, may be less effective for patients with ARFID. This study first describes a pediatric sample of patients with ARFID upon admission to an inpatient service. Then, a case series is used to illustrate the potential benefits of using an adjusted protocol that was modified to better suit the needs of children and adolescents with ARFID. Findings support future study of the proposed adjusted protocol and may inform future standardization of improved care for this high priority clinical population.

An exploration of the association between premorbid weight status on patient and caregiver factors at pre and post-treatment among youth with anorexia nervosa/atypical anorexia nervosa.

Patients with atypical anorexia nervosa (AAN) or anorexia nervosa (AN) with premorbid history of higher weight (PHW; median BMI ≥ 85th %ile) may report greater eating disorder (ED) pathology, anxiety, and depression, than patients with premorbid history of lower weight (PLW; mBMI <85th %ile). Less is known about caregiver attitudes or treatment outcome related to premorbid weight history. The current study examined associations between premorbid weight history and patient/caregiver factors at presentation, during treatment, and end of treatment among adolescents (N = 138) diagnosed with AN/AAN and their caregivers who received interdisciplinary ED treatment. The sample comprised adolescents with PHW (n = 58, 40.6 %) or PLW (n = 82, 59.4 %). Adolescents with PHW did not differ with regard to patient- or caregiver-reported ED symptoms, comorbid psychopathology, rates of treatment completion, and attainment of estimated body weight compared to PLW (ps > .05). Adolescents with PHW (vs. PLW) were more likely to be diagnosed with AAN (67.9 %, p < .001), identify as cisgender male (p < .001) and to have lost more weight prior to presentation (p < .001). Perceived caregiver burden was lower among adolescents with PHW vs. PLW (p < .001). Further research should expand on this preliminary study exploring associations between premorbid weight history on patient and caregiver factors at treatment presentation and conclusion to enhance the efficacy of evidence-based treatment across the weight-spectrum.

Considerations in Evidence-Based Treatment of Adolescents With Atypical Anorexia Nervosa.

There is emerging evidence suggesting atypical anorexia nervosa (AAN), an eating disorder (ED) introduced in the DSM-5, is as serious an ED as anorexia nervosa (AN) in terms of medical risk and ED pathology. Medical hospitalizations among individuals with AAN have significantly increased over the years and individuals with AAN are noted to have longer illness durations and greater weight loss prior to receiving care than individuals with AN. Additionally, AAN is noted to be two to three times more common than AN in community samples of adolescents. Given that AAN is a newer diagnosis, research knowledge and evidence-based treatment guidelines are emerging, yet pivotal. Thus, this article discusses specific considerations during assessment and treatment using Family Based Treatment (FBT) among adolescents diagnosed with AAN and clinical and ethical concerns involved while providing effective care and mitigating any weight bias or stigma related to historical and current weight status.

Predictors of caregiver burden before starting family-based treatment for adolescent anorexia nervosa and associations with weight gain during treatment.

PURPOSE: Caregivers play a pivotal role in the success of family-based treatment (FBT) for anorexia nervosa (AN). Caregiver burden is frequently demonstrated in eating disorders (EDs) and may impact FBT outcomes. This study examined factors associated with caregiver burden before starting FBT and whether pre-treatment caregiver burden was associated with weight gain during FBT. METHODS: Participants included 114 adolescents with AN or atypical AN (mean age = 15.6 years, SD = 1.4) and a primary caregiver (87.6% mothers) who received FBT in the United States. Before starting treatment, participants completed self-report measures of caregiver burden (via the Eating Disorder Symptom Impact Scale), caregiver anxiety, caregiver depression, and ED symptoms. Clinical characteristics and percentage of target goal weight (%TGW) at FBT session 1 and 3 and 6 months after starting treatment were obtained via retrospective chart review. Hierarchical regressions examined predictors of caregiver burden before FBT initiation. Associations between pre-treatment caregiver burden and %TGW gain at 3 and 6 months after starting FBT were assessed with hierarchical regressions. RESULTS: Caregiver anxiety (p < 0.001), family history of EDs (p = 0.028), adolescent mental health treatment history (p = 0.024), and ED symptoms (p = 0.042) predicted caregiver burden before starting FBT. Pre-treatment caregiver burden was not associated with %TGW gain at 3 or 6 months. Males demonstrated less %TGW gain than females at 3 months (p = 0.010) and 6 months (p = 0.012). CONCLUSION: Proactively evaluating caregiver burden before starting FBT is suggested. Providing recommendations and/or referrals for identified caregiver vulnerabilities could indirectly impact FBT progress. Males in FBT could require longer courses of treatment and extra vigilance to this demographic is suggested. LEVEL OF EVIDENCE: Level III, case-control analytic study.

Clinical characteristics of medically hospitalized youth with anorexia nervosa/atypical anorexia nervosa and premorbid overweight/obesity.

Youth with anorexia nervosa (AN) or atypical anorexia nervosa (AAN) and premorbid overweight/obesity are particularly vulnerable to diagnostic delays, yet research about this patient subset is lacking. This study aimed to compare mental health and demographic characteristics of patients with AN/AAN and premorbid overweight/obesity to patients with premorbid normal weight. Retrospective chart review identified 253 patients (aged 10-22) hospitalized for medical complications of AN/AAN between 2013 and 2020, including 29.6% (n = 75) with and 70.4% (n = 178) without premorbid overweight/obesity. Analyses revealed that patients with AN/AAN and premorbid overweight/obesity were more often cisgender male (24% vs. 8.4%), diagnosed with AAN (62.7% vs. 32%), and had lost a greater percent of body weight (29% vs. 16.4%) than premorbid normal weight counterparts. No significant differences were found for illness duration (10.1 months vs 9.3 months), psychiatric comorbidities (42.7% vs. 32.2%) or psychotropic medication use (25.3% vs. 19.2%), past mental health treatment (44.6% vs. 37.5%), or family history of eating disorders (22.7% vs. 20.8%). Our findings suggest that when relying on historical records, patients hospitalized for medical complications of AN/AAN have similar characteristics across the weight spectrum.

Eating disorder severity and psychological morbidity in adolescents with anorexia nervosa or atypical anorexia nervosa and premorbid overweight/obesity.

PURPOSE: A significant proportion of adolescents with anorexia nervosa (AN) or atypical anorexia nervosa (AAN) experience premorbid overweight/obesity, yet distinct characteristics among this subset of patients remain unclear. This study examined eating disorder (ED) symptom severity, psychological morbidity, and weight stigma in patients with premorbid overweight/obesity as compared to patients with premorbid normal weights. METHODS: Participants included adolescents with AN or AAN (aged 12-18) who received multidisciplinary treatment at a pediatric medical center in the United States. ED symptoms, anxiety, and depression were compared among patients with premorbid overweight/obesity (n = 43) and premorbid normal weights (n = 63). Associations between weight stigma, ED severity, and psychological morbidity were also examined. RESULTS: Patients with premorbid overweight/obesity reported greater ED severity (p = 0.04), anxiety (p < 0.003), depression (p = 0.02), and a higher frequency of weight-based teasing by peers (p = 0.003) and parent weight talk about their own weights (p < 0.001). Weight-based teasing was positively associated with ED symptoms, anxiety, and depression for all patients, regardless of premorbid weight status. CONCLUSIONS: Adolescents with AN or AAN and a history of overweight/obesity may present with greater ED symptom severity and psychological morbidity than patients with normal weight histories. Distinct prevention and treatment interventions for adolescents with AN or AAN and premorbid overweight/obesity may be warranted. LEVEL OF EVIDENCE: Level III, case-control analytic study.

Intermittent fasting implementation and association with eating disorder symptomatology.

Intermittent fasting (IF) is an emerging dietary trend that remains understudied. This study aimed to describe the implementation and eating disorder (ED) symptomatology, relevant to engagement in IF among both men and women. Intermittent fasters (N = 44 women, N = 20 men) recruited from Amazon Mechanical Turk, Reddit, and a Midwestern University were administered a demographic questionnaire, an assessment of ED symptomatology (Eating Disorder Examination Questionnaire; EDE-Q), and asked about their IF use. To assess the level of ED symptomatology among individuals using IF community and clinical norms were used for comparison. We hypothesized a) men and women engaging IF would score higher on the EDE-Q and b) more individuals engaging in IF would endorse ED behaviors (e.g., self-induced vomiting) than community norms. Intermittent fasters reported fasting for approximately 16 hours daily and for weight loss purposes. Men and women engaging in IF scored significantly higher than community norms on all subscales of the EDE-Q, with 31.25% of participants' EDE-Q scores being at or above the clinical EDE-Q cut-off. Men and women engaging in IF reported engaging in ED behaviors. Results suggest that IF is associated with ED symptomatology. Further research on psychological characteristics and temporal order of the association between IF and ED symptomatology is warranted.

Higher admission and rapid readmission rates among medically hospitalized youth with anorexia nervosa/atypical anorexia nervosa during COVID-19.

The COVID-19 pandemic has had sweeping and deleterious effects on the well-being of individuals worldwide. Eating disorders (EDs) are no exception, with incidence and prevalence of EDs rising since COVID-19 onset. The current study examined inpatient census and readmission rates among youth (aged 8-18) hospitalized for medical complications of anorexia nervosa (AN) or atypical anorexia nervosa (AAN) throughout distinct periods of the COVID-19 pandemic, including pre-COVID-19 (n = 136), COVID-19 lockdown (n = 3), and post COVID-19 lockdown (n = 24). Data from the COVID-19 lockdown period was excluded from analyses due to low sample size. Youth hospitalized during post COVID-19 lockdown were over 8-times more likely to be readmitted within 30-days of discharge compared to patients hospitalized before the pandemic (p = .002). Further, the inpatient census of youth with AN/AAN was significantly higher during post COVID-19 lockdown compared to pre-COVID-19 (p = .04). One-third of patients hospitalized since the pandemic identified COVID-19 consequences as a primary correlate of their ED. Our findings, although not causal, suggest an association between COVID-19 and AN/AAN development and exacerbation in youth, thus prompting more medical admissions and rapid readmissions among this demographic. This study has important implications for understanding how AN/AAN onset and exacerbation in youth has been affected by the COVID-19 pandemic and can inform new efforts to support individuals navigating treatment during a global crisis.

The medial prefrontal cortex: a potential link between self-deception and affect.

The Medial Prefrontal Cortex (MPFC) is crucial for normal social functioning in humans. Because of its involvement in social monitoring, self-awareness, and self-enhancement, the MPFC may be critical to buffering negative affect and establishing a positive self-esteem. For example, we have previously found that disruption of the MPFC leads to more honest responses, which implies that the MPFC may be critically involved in self-deception. We therefore hypothesized that disrupting the MPFC would lead to a decrease in affect. Employing a virtual lesion TMS (Transcranial Magnetic Stimulation) technique, we disrupted the MPFC while participants rated their mood based on two anchor affect terms. During TMS, the participants rated their current emotional mental state. Compared to sham TMS, it was found that mood was reduced immediately following single-pulse MPFC stimulation. The results supported the hypothesis the MPFC mood reduction occurs when the MPFC is disrupted. Because this study replicated the conditions employed in previous self-deception studies, we suggest that the results may indicate that lack of self-enhancement may lead to a decrease in mood. Further studies should examine this possibility.

Modifiable factors associated with mental health symptoms in siblings of adolescents with anorexia nervosa.

PURPOSE: Research demonstrates that anorexia nervosa (AN) takes a significant toll on affected families, yet the well-being of siblings has been largely overlooked. This study examines mental health symptoms in siblings of adolescents with AN and seeks to identify modifiable factors associated with well-being. METHOD: Participants included 34 siblings (aged 11-19) of adolescents with AN and 47 age and sex matched controls. Participants and their caregivers completed assessments of anxiety, depression, internalizing and externalizing problems, and parentification. Siblings of adolescents with AN also completed the Sibling Perception Questionnaire, an assessment of perceptions and attitudes about AN. RESULTS: Analyses indicated that siblings of adolescents with AN reported greater anxiety and parentification than controls. On caregiver reports of participants' internalizing and externalizing symptoms, no significant differences were found across groups. In siblings of adolescents with AN, females were more vulnerable to anxiety, depression, and negative attitudes and perceptions about AN than males. Perceived negative interpersonal interactions, specific to having a brother or sister with AN, were associated with greater anxiety and depression among AN siblings. CONCLUSION: Findings from this pilot study suggest that siblings of adolescents with AN are vulnerable to anxiety and parentification behaviors. Negative interpersonal interactions specific to having a brother or sister with AN may perpetuate risk for poorer well-being. Caregivers may not be attuned to these struggles, highlighting the importance of provider and family education about sibling vulnerabilities. Therapeutic interventions that target siblings of adolescents with AN are also indicated. LEVEL OF EVIDENCE: Level III, case-control analytic study.

Yoga Practice in a College Sample: Associated Changes in Eating Disorder, Body Image, and Related Factors Over Time.

Yoga practice is associated with improvements in eating disorder (ED) symptoms and body dissatisfaction. This study continued to evaluate this relationship while also assessing changes in variables negatively associated with ED symptoms (self-compassion, mindfulness, body appreciation, self-efficacy) that are emphasized throughout yoga. Men were also included in this study given studies have predominantly focused on women. Participants (N = 99, 77.8% women) were recruited from a university-implemented yoga course and completed assessments at the beginning (Time 1 (T1)) and end (Time 2 (T2)) of an eight-week yoga course meeting three times a week for fifty minutes. Body dissatisfaction (ps <.05) and ED pathology (p = .02) were lower at T2. Body appreciation (p < .001), self-compassion (p = .01), yoga self-efficacy (p = .004) were higher at T2. Some gender differences emerged. Men reported greater reductions in concern with being overweight, (Overweight Preoccupation) from T1 (M = 2.46, SD = 0.61) to T2 (M = 2.13, SD = 0.61) compared to women, T1 (M = 2.75, SD = 0.98) to T2 (M = 2.69, SD = 0.97) associated with yoga practice. Men also reported greater improvements in body satisfaction (Appearance Evaluation) from T1 (M = 3.60, SD = 0.49) to T2 (M = 3.90, SD = 0.34) compared with women, T1 (M = 3.48, SD = 0.58) to T2 (M = 3.39, SD = 0.52) associated with yoga practice. Results suggest yoga may be associated with concurrent changes in protective and risk factors for ED in a college population.

Ensuring a competent public health responder workforce: The CDC experience.

INTRODUCTION: From 2009 to 2016, the Centers for Disease Control and Prevention (CDC) activated its Incident Management System for a public health emergency 91 percent of the time. The CDC must ensure its workforce is prepared for the evolving nature of emergencies. OBJECTIVES: The purpose of this assessment was to identify perceived preparedness and response training needs for the CDC responder workforce. METHODS: Between November 2012 and January 2013, focus groups and in-depth interviews were conducted with CDC responders, including senior leaders. The evaluation questions were: (1) How well does the current training system prepare CDC staff to respond to emergency events? (2) What gaps exist in the current training system? and (3) What trainings are essential and should be included in the training system? RESULTS: Eight focus groups were conducted with 51 responders and 18 interviews with response leaders. Themes were identified for each main outcome measure and translated to training improvements. CONCLUSIONS: The CDC workforce received foundational training. Recommendations are provided to better prepare responders during an emergency. Periodic assessments are necessary to expand training and remain responsive to the complexities of emerging threats.

Late organ failures in patients with prolonged intensive care unit stays.

PURPOSE: The purpose of this study was to characterize the organ failures that develop among patients with prolonged ICU stays, defined as those who spent a minimum of 14 days in an ICU. METHODS: We retrospectively studied a cohort of consecutive patients from a university hospital who were in an ICU for a minimum of 14 days during 2014-2016. We calculated daily Sequential Organ Failure Assessment (SOFA) scores from admission to ICU day 14. The primary outcome was the number of new late organ failures, defined as occurring on ICU day 4 through 14. RESULTS: In a retrospective cohort of 3777 consecutive patients in six ICUs, 50 patients had prolonged ICU stays. Of those 50, new cardiovascular failure occurred in 24 (62%) on day 4 or later; persistent mechanical ventilation was present in only 28 (56%). CONCLUSIONS: Strategies aiming to reduce the development of new late organ failures may be a novel target for preventing persistent critical illness.

Speed of Processing Time Slowing in Eating Disorders.

We applied Brinley ( 1965 ) plot analysis to the eating disorders field. Across 23 studies and 165 experimental conditions [experienced by a total of 773 eating disorder (ED) participants, including anorexia nervosa (AN), binge eating (BE), bulimia nervosa (BN), and eating disorders not otherwise specified (EDNOS) and 995 controls], the best-fit regression equation was Y (ED) = 1.08 X (CONTROL) - 31. This equation accounted for 98.2% of the variance. Thus, the ED subjects were only 1.08 times slower than the control subjects, suggesting little processing speed slowing in ED. We also examined simple reaction time [SRT; Y (ED) = .91 X (CONTROL) + 63; variance accounted for = 93.6%] and choice reaction time (CRT; Y (ED) = 1.12X (CONTROL) - 43, variance accounted for = 99.7%). These slopes are significantly different. ED subjects are more impacted when the task involves a decision component (CRT) than when it does not (SRT).

Are antimicrobial peripherally inserted central catheters associated with reduction in central line-associated bloodstream infection? A systematic review and meta-analysis.

BACKGROUND: Antimicrobial peripherally inserted central catheters (PICCs) may reduce the risk of central line-associated bloodstream infection (CLABSI). However, data regarding efficacy are limited. We aimed to evaluate whether antimicrobial PICCs are associated with CLABSI reduction. METHODS: MEDLINE, EMBASE, CINHAL, and Web of Science were searched from inception to July 2016; conference proceedings were searched to identify additional studies. Study selection and data extraction were performed independently by 2 authors. RESULTS: Of 597 citations identified, 8 studies involving 12,879 patients met eligibility criteria. Studies included adult and pediatric patients from intensive care, long-term care, and general ward settings. The incidence of CLABSI in patients with antimicrobial PICCs was 0.2% (95% confidence interval [CI], 0.0%-0.5%), and the incidence among nonantimicrobial catheters was 5.3% (95% CI, 2.6%-8.8%). Compared with noncoated PICCs, antimicrobial PICCs were associated with a significant reduction in CLABSI (relative risk [RR], 0.29; 95% CI, 0.10-0.78). Statistical heterogeneity (I2, 71.6%; T2 = 1.07) was resolved by publication type, with peer-reviewed articles showing greater reduction in CLABSI (RR, 0.21; 95% CI, 0.06-0.74). Twenty-six patients (95% CI, 21-75) need to be treated with antimicrobial PICCs to prevent 1 CLABSI. Studies of adults at greater baseline risk of CLABSI experienced greater reduction in CLABSI (RR, 0.20; P = .003). CONCLUSIONS: Available evidence suggests that antimicrobial PICCs may reduce CLABSI, especially in high-risk subgroups. Randomized trials are needed to assess efficacy across patient populations.

Internet-Delivered Health Interventions That Work: Systematic Review of Meta-Analyses and Evaluation of Website Availability.

BACKGROUND: Due to easy access and low cost, Internet-delivered therapies offer an attractive alternative to improving health. Although numerous websites contain health-related information, finding evidence-based programs (as demonstrated through randomized controlled trials, RCTs) can be challenging. We sought to bridge the divide between the knowledge gained from RCTs and communication of the results by conducting a global systematic review and analyzing the availability of evidence-based Internet health programs. OBJECTIVES: The study aimed to (1) discover the range of health-related topics that are addressed through Internet-delivered interventions, (2) generate a list of current websites used in the trials which demonstrate a health benefit, and (3) identify gaps in the research that may have hindered dissemination. Our focus was on Internet-delivered self-guided health interventions that did not require real-time clinical support. METHODS: A systematic review of meta-analyses was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO Registration Number CRD42016041258). MEDLINE via Ovid, PsycINFO, Embase, Cochrane Database of Systematic Reviews, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched. Inclusion criteria included (1) meta-analyses of RCTs, (2) at least one Internet-delivered intervention that measured a health-related outcome, and (3) use of at least one self-guided intervention. We excluded group-based therapies. There were no language restrictions. RESULTS: Of the 363 records identified through the search, 71 meta-analyses met inclusion criteria. Within the 71 meta-analyses, there were 1733 studies that contained 268 unique RCTs which tested self-help interventions. On review of the 268 studies, 21.3% (57/268) had functional websites. These included evidence-based Web programs on substance abuse (alcohol, tobacco, cannabis), mental health (depression, anxiety, post-traumatic stress disorder [PTSD], phobias, panic disorders, obsessive compulsive disorder [OCD]), and on diet and physical activity. There were also evidence-based programs on insomnia, chronic pain, cardiovascular risk, and childhood health problems. These programs tended to be intensive, requiring weeks to months of engagement by the user, often including interaction, personalized and normative feedback, and self-monitoring. English was the most common language, although some were available in Spanish, French, Portuguese, Dutch, German, Norwegian, Finnish, Swedish, and Mandarin. There were several interventions with numbers needed to treat of <5; these included painACTION, Mental Health Online for panic disorders, Deprexis, Triple P Online (TPOL), and U Can POOP Too. Hyperlinks of the sites have been listed. CONCLUSIONS: A wide range of evidence-based Internet programs are currently available for health-related behaviors, as well as disease prevention and treatment. However, the majority of Internet-delivered health interventions found to be efficacious in RCTs do not have websites for general use. Increased efforts to provide mechanisms to host "interventions that work" on the Web and to assist the public in locating these sites are necessary.

Impact of the 2012 extreme drought conditions on private well owners in the United States, a qualitative analysis.

BACKGROUND: Extreme hot and dry weather during summer 2012 resulted in some of the most devastating drought conditions in the last half-century in the United States (U.S.). While public drinking water systems have contingency plans and access to alternative resources to maintain supply for their customers during drought, little is known about the impacts of drought on private well owners, who are responsible for maintaining their own water supply. The purpose of this investigation was to explore the public health impacts of the 2012 drought on private well owners' water quality and quantity, identify their needs for planning and preparing for drought, and to explore their knowledge, attitudes, and well maintenance behaviors during drought. METHODS: In the spring of 2013, we conducted six focus group discussions with private well owners in Arkansas, Indiana, and Oklahoma. RESULTS: There were a total of 41 participants, two-thirds of whom were men aged 55 years or older. While participants agreed that 2012 was the worst drought in memory, few experienced direct impacts on their water quantity or quality. However, all groups had heard of areas or individuals whose wells had run dry. Participants conserved water by reducing their indoor and outdoor consumption, but they had few suggestions on additional ways to conserve, and they raised concerns about limiting water use too much. Participants wanted information on how to test their well and any water quality issues in their area. CONCLUSIONS: This investigation identified information needs regarding drought preparedness and well management for well owners.

Evaluation of a Blocked-Trials Procedure to Establish Complex Stimulus Control over Intraverbal Responses in Children with Autism.

We evaluated the use of a blocked-trials procedure to establish complex stimulus control over intraverbal responses. The participants were four young boys with a diagnosis of autism who had struggled to master intraverbals. The blocked-trials procedures involved presentation of stimuli in separate trial blocks. The trial blocks gradually reduced in size contingent upon correct responding, until the stimuli were presented in quasi-random order. All participants acquired multiple discriminations with the blocked-trials procedure, although additional procedures were needed to teach the first discrimination with two participants. Following acquisition of multiple discriminations, two participants acquired a novel discrimination with quasi-random presentation of stimuli, and a third participant demonstrated discriminated responding in intraverbal probes.