A descriptive analysis of self-injury in community settings: exploring behaviour-behaviour contingencies.

BACKGROUND: Self-injurious behaviour (SIB) is a treatment-resistant aberrant behaviour that significantly impacts the lives of people with intellectual disabilities (ID). Direct observations of SIB under naturally occurring conditions can inform the unique structural properties of these behaviours, and the contexts in which they occur. While previous applications of sequential analyses have identified strong temporal associations between instances of SIB, they have relied on methods that do not adequately control for chance sequencing and may mask within-participant variability by pooling data across contexts and response topographies. We applied a new sequential analysis method to quantify SIB-SIB contingencies within and across topographies for individuals with ID in community settings. We also explored the extent to which the direction and strength of SIB-SIB contingencies varied by context. METHOD: Seven individuals with chronic SIB were video-recorded during their daily routines. A continuous, timed-event data collection system was used to measure frequencies of five topographies of SIB and duration of staff interactions. We used an event lag with pauses sequential analysis method to estimate SIB-SIB contingencies within and across topographies and during times with and without staff interaction. RESULTS: Positive SIB-SIB contingencies were identified for all participants, with contingency strengths varying among participants and topographies. The strength and direction of the SIB-SIB contingencies also varied by the presence and absence of staff interaction. CONCLUSIONS: Our results suggest the direction and strength of SIB-SIB contingencies may be fluid based on the presence or absence of certain environmental context variables. Evaluating SIB-SIB contingencies under different environmental conditions may help identify contexts in which SIB is likely to persist.

Comparing sequential associations within a single dyad.

We present a new application of sampled permutation testing to examine whether two sequential associations are different within a single dyad (e.g., a teacher and a student). A Monte Carlo simulation with the same (i.e., 100 vs. 100) or a different (100 vs. 400) number of event pairs was used to simulate designs that use time-based (typically producing equal-length comparisons) and event-based (typically producing different-length comparisons) data, respectively. For these pairs of simulated data streams, we compared the Type I error rates and the kappa for agreement on significance decisions, using the sampled permutation tests and the more traditional asymptotic log linear analysis. The results provide the first evidence relevant to evaluating the accuracy of log linear analysis and sampled permutation testing for the purpose of comparing sequential associations within a single dyad.

Sequential analysis of the effects of naltrexone on the environmental mediation of self-injurious behavior.

Accumulated evidence shows that biology and the environment can mediate self-injurious behavior (SIB) in persons with mental retardation. Whether pharmacological treatment alters the environmental mediation of self-injury is unclear. Opioid antagonist effects on sequential dependencies for self-injury were studied in the context of experimental single-subject double-blind placebo-controlled designs. Direct observational data were collected for 4 adult subjects in real time on daily rate of SIB and staff interactions. Clinically significant reductions (i.e., > or = 33%) in SIB rate were observed for 3 of the 4 subjects. For all subjects, the magnitude of the sequential dependency between staff behavior and self-injury was significantly greater during treatment with naltrexone than during treatment with a placebo. Results are discussed in relation to behavioral mechanisms of action regulating medication effects for self-injury.

Aquatic toxicity testing of sparingly soluble, volatile, and unstable substances and interpretation and use of data. Task Force of the European Centre for Ecotoxicology and Toxicology of Chemicals.

Aquatic toxicity tests were originally designed for individual compounds that are soluble and stable in water. For sparingly soluble substances that are not toxic at the solubility limit, the issue is whether tests should be performed with insoluble test substance present. Based on a literature evaluation of the physiology of uptake, it was concluded that only the dissolved fraction is available for uptake and that the insoluble test substance may introduce artifacts that aggravate data interpretation. Therefore, toxicity tests should be conducted only up to the solubility limit. Testing of volatile, unstable, or adsorptive substances is complicated by the ability to keep exposure concentrations relatively constant. For these, appropriate test protocols including adequate design of the dosing systems must be employed. For test medium preparation, physical methods and, where necessary, use of low concentrations of certain solvents are recommended to support handling and speed of dissolution. However, recommendation is made against the use of dispersants. Water-accommodated fractions are recommended as one approach for dosing multicomponent substances. Interpretation of observed effects depends on appropriate test medium preparation, correct measurement and expression of exposure levels, and differentiation of true toxicity from indirect physical effects of the substance, or the toxicity of impurities.

The psychosocial review: evaluating development and implementation in a family practice residency.

This paper presents a comprehensive system for family physicians to use in integrating psychological and social dimensions into everyday practice. Called the Psychosocial Review, this set of techniques includes a structured format for gathering information, making goal-focused assessments, and developing treatment plans. A framework for training family practice residents in the system is detailed. A research project evaluating the application of this program in two resident office practices is described. Results indicated that residents acquired information-gathering skills, but remained deficient in incorporating data into assessment and treatment. Implications for training are discussed, with the conclusion that a collaborative effort between behavioral science faculty and family physician faculty, including an emphasis on direct observation and supervision, appears to be the most promising approach to training family practice residents in behavioral science.

Resident physician performance in a continuing education format. Does newly acquired knowledge improve patient care?

As part of an educational program in preventive dentistry for family medicine residents, we evaluated changes in systemic fluoride prescribing habits related to newly acquired knowledge. Residents, unaware of the study, were randomly assigned to one of two groups and shown a videotape describing preventive dental techniques. We supplemented the tape viewed by one group with specific instructions explaining the implementation of the information in patient care. Residents in both groups demonstrated the ability to learn and maintain their level of knowledge during a three-month period. Daily chart audits, however, revealed no substantial increase in correct prescribing of systemic fluoride to pediatric patients for either group. Only subsequent individual monitoring and reinforcement achieved the desired behavior. The acquisition of new knowledge by resident physicians under these circumstances did not lead to its application in daily patient care. This result parallels reported difficulties in altering physician behavior by continuing medical education, and suggests that residency programs are an appropriate setting to initiate improved physician performance in response to acquired knowledge.

A structured experiential curriculum in community medicine.

In order to provide experimental training in community medicine, a structured curriculum has been developed. Specific methodological skills in community medicine are identified and nine content areas are presented in seminar form during the three-year training program. Each resident is expected to participate in a community health care project and demonstrate one or more of the methodological skills identified. The experiences of two residents are reported. One involved a community health needs assessment and one, the development of a mechanism to ensure continuing consumer/provider communication.

The application of behavior modification to behavior management: guidelines for the family physician.

Treatment in ambulatory care settings depends on the patient's behavior to implement the regimen prescribed by the family physician. Behavior modification offers a means for developing behavioral programs that will improve the physician's ability to effectively influence the patient's behavior. This article outlines some of the principles of behavior modification as they can be applied in office settings to diverse behavioral problems. Some specific suggestions are made for identifying behaviors, setting goals, delineating the steps to reach these goals, monitoring progress, and developing treatment contracts that will aid the physician in the management of the behavioral aspects of treatment.

Evaluation of mental health service effectiveness: a "start up" model for established programs.

The practical difficulties of using the experimental model for program evaluation in direct service settings are discussed, and it is suggested that use of this model seems premature. These difficulties, however, can no longer be used as a rationale for delaying program evaluation. A practical alternative model is outlined.

Criteria for appropriate and inappropriate referrals to a crisis clinic.

The purpose of this study was to develop criteria for appropriate and inappropriate referrals by telephone counselors to a crisis clinic. Interviews were conducted with staff members and volunteers of the Suicide Prevention and Crisis Service to explore possible criteria for making a referral. Nine criteria for inappropriate referrals and eight criteria for appropriate referrals were established. Data were then collected from a larger sample of staff members and volunteers (N=56) in the form of a ranked-order questionnaire, and differences between the staff and volunteers were examined. Rankings were significantly different for only 2 of the 17 categories suggesting that there is general agreement between staff and volunteers on the criteria for appropriate and inappropriate referrals for counseling. Policy implications of the accepted criteria are discussed.

The prediction of "shows" and "no-shows" to a crisis center: a replication.

The relationship between measures of worker effectiveness in a therapeutic telephone intervention and whether a caller shows for a scheduled appointment can be used to assess the variables that contribute to "successful" telephone counseling. This study replicated the findings of a previous investigation in showing that the motivation of a caller in response to the question of a referral was positively correlated with "showing" for the appointment. Futher, the identification of a specific problem related negatively to the caller's response to the referral. However, the concreteness of the phone worker was not correlated with whither the scheduled appointment was kept by the caller.

Compliance from kindergarten to college: A speculative research note.

Focused on children's developing ideas of rule, justice, and compliance, interview data from 115 subjects in kindergarten through college are used to reconstruct the jurisprudence-or legal value system-of youth. This investigation of normal legal reasoning (1) clarifies changing conceptions of roles vis-à-vis rule systems and (2) assesses the products and potential of legal socialization. Developmentally, youth see rules guarding against disorder and functioning as more prospective than coercive, prescriptive than prohibitive, beneficial than punitive, and dynamic than sacred. Parallel changes emerge in defining role relationships. By their own assessment, youth's perceptions are guided by a law-and-order frame, although they recognize that purpose and principle should determine compliance. For most, neither absolutist positions nor authoritative fiats insure justice. Optimally, justice is guaranteed through equality, rationality, consensus, and human rights. Only a modest number, however, accept that they can internalize these principles and, in judging the system by them, not be obligated to obey an unfair rule. While youth have the capacity for legal reasoning consistent with principles of major jurisprudents, to attain such ethical legality, socializing agents must define new goals, appraise old values, and create conducive contexts.