Evaluation of a preventive intervention for maltreated infants and toddlers in foster care.

OBJECTIVE: To determine the effectiveness of an intervention designed to improve outcomes for infants and toddlers in foster care. METHOD: Records were reviewed for all children who were adjudicated as in need of care in a specific parish in Louisiana between 1991 and 1998. This period included 4 years before and 4 years after a comprehensive intervention was implemented. Children adjudicated between 1991 and 1994 were the comparison group, and those adjudicated between 1995 and 1998 were the intervention group. RESULTS: After the intervention, more children were freed for adoption and fewer children were returned to their birth families than before the intervention. There was no difference in length of time in care before and after the intervention. With regard to the same child returning in a subsequent incident of maltreatment, relative risk reduction for the intervention group ranged from 53% to 68%. With regard to the same mother maltreating another child subsequently, relative risk reduction for the intervention group ranged from 63% to 75%. CONCLUSIONS: A comprehensive preventive intervention for maltreated infants and toddlers in foster care substantially reduced rates of recidivism but had no effect on length of time in care.

Attachment and developmental psychopathology.

This article describes the case of an 8-year-old boy who was first brought to clinical attention at age 2 1/2. He was followed by several clinicians over a 6-year period and was assigned a wide variety of diagnoses. From the first assessment to hospitalization at age 8, a pattern of mother-child relationship disturbance is evident. The use of principles and recent research derived from attachment theory provides a useful basis for formulation in this complex case. This report focuses on the relationship between the patient's mother's internal working models of attachment and his behavior in infancy and early childhood.

Research on resilience to child maltreatment: empirical considerations.

OBJECTIVE: To review the current research literature on resilience to maltreatment in childhood and adolescence. METHOD: First, this paper addresses the methodological issues applicable to this area of research. Second, it reviews the empirical literature on the protective factors believed to contribute to resilience to maltreatment and offers commentary on specific issues raised in each study. RESULTS: The current findings are summarized and an integrated descriptive picture, based on the extant literature of the processes and factors contributing to the development of resilience to childhood maltreatment is outlined. CONCLUSION: Based on this extensive review and critique of the current empirical literature on resilience to maltreatment, suggestions for future investigations in this area are recommended.

Psychosocial outcome after ICD implantation: a current perspective.

Depression and reduced sexual functioning have been identified as problems following ICD placement. We examined these issues, and multiple other quality-of-life measures, and their relationship to ICD and ICD discharge. Patients were 64 +/- 11 years old, 72% male, and had undergone ICD 20 +/- 14 months previously. Fifty-eight patients responded to a confidential biopsychosocial questionnaire. Positive attitudes toward the procedure increased from 52% before to 76% after implantation. Satisfaction correlated most strongly with less anger (P = 0.002, r = 0.45), less worry about ICD size (P = 0.007, r = 0.38), less sadness (P = 0.01, r = 0.37), and perceived better health (P = 0.01, r = 0.35). Of these ICD patients, 20%-58% reported measures of depression, and sexual frequency was reduced in 45%. Despite successful ICD placement, health concern increased in 62% of the respondents. Thirty-nine percent attended support groups; 96% found them very helpful. Mean number of ICD discharges described by responders was 5 +/- 11. Fifty percent of our sample reported > or = 1 shock; equal numbers had 1, 2-5, 6-10, and more than 10 shocks. Sixty-two percent of men had at least one discharge compared to 13% of women. After controlling for cardiac clinical variables, experiencing > or = 1 ICD shock was strongly associated with anxiety about family (odds ratio = 7.3), reduced new activities (odds ratio = 6.9), increased sadness (odds ratio = 6.2), and health worry (odds ratio = 5.8). Experiencing > or = 5 ICD shocks was strongly associated with increased health concern (odds ratio = 13.6), increased sadness (odds ratio = 12.5), increased fatigue (odds ratio = 6.1), current sadness (odds ratio = 5.8), and increased nervousness (odds ratio = 5.3). ICD implantation powerfully affects quality-of-life. Postimplantation health concern is paradoxically increased despite improvement in actual health. Negative emotions are associated with defibrillator discharge.

Attachment disorders in infancy and early childhood: a preliminary investigation of diagnostic criteria.

OBJECTIVE: The primary purpose of this study was to compare the reliability of differing sets of criteria for attachment disorders by using a retrospective case review. METHOD: Forty-eight consecutive clinical case summaries from an infant behavior clinic were reviewed by four experienced clinicians. Attachment disorders were coded as present or absent by using competing criteria and were scored by using a continuous scale of relationship functioning. RESULTS: The reliability of alternative criteria was acceptable, but the reliability of DSM-IV criteria in diagnosing attachment disorders was marginal. Preliminary validity for the criteria was demonstrated by the fact that more severe relationship disturbances were seen in infants diagnosed with attachment disorders than in infants diagnosed with other disorders. CONCLUSIONS: Standardized assessments of at-risk populations should be used to replicate these preliminary results; revision of DSM-IV criteria may be necessary to obtain adequate reliability for diagnosing attachment disorders.

The timing of psychiatric consultation requests. Utilization, liaison, and diagnostic considerations.

Psychiatric consultation timing results from the interaction of multiple systems. This study examines the key clinical and systems variables and the effect of consultation timing on subsequent length of hospital stay. One hundred and forty-five consecutive psychiatric consultations at a New York City teaching hospital were assessed by demographic criteria, medical and psychiatric diagnoses, reasons for consultation, and the timing of the consultation with respect to the academic year. Twenty-five percent of the consultations occurred within the first 48 hours after admission and 32% occurred between Days 2 and 5. Consultations for schizophrenia patients were called earlier (P < 0.02) than those for patients with other diagnoses, and those for patients with the acquired immunodeficiency syndrome were called later (P < 0.04). Earlier consultations were associated with a shorter time to discharge (P < 0.002).

The process of coping with a gross anatomy exam during the first year of medical school.

A total of 42 freshman medical students were evaluated before a major exam, after the exam and before grades were announced and after grades were announced. They completed measures relating to mood, emotions, coping, social support and stakes. Significant time and academic performance differences were found in many domains.

The transfer of adaptation between actual and simulated rotary stimulation.

It is well known that continued exposure to motion environments leads to adaptation, but it is not clear whether such changes are specific to the particular type of motion experienced. The present investigation sought to evaluate the extent of transfer between real motion and visually-induced apparent motion. In addition, the direction of motion was varied and these two factors, mode of exposure and direction of rotation, were examined in a cross-adaptational design. Thirty-two subjects were pre- and posttested on measures of disorientation after active bodily rotation and visually-induced self-vection. Two groups received ten consecutive trials of active bodily rotation (clockwise or counter-clockwise) for 4 consecutive days. Two other groups received ten consecutive trials of visually-induced self-vection (clockwise or counter-clockwise) in a rotating drum for 4 consecutive days. During the exposure phase, dizziness and self-vection increased over trials for the groups exposed to the drum, while dizziness remained unchanged over trials for the groups exposed to bodily rotation. Repeated exposure to bodily rotation resulted in improved walking performance over trials and days. Subjects exposed to bodily rotation exhibited increased tolerance to visually-induced self-vection; however, exposure to visually-induced self-vection did not result in greater tolerance to bodily rotation. No support for directional specificity was evident.

Type A behavior and survival after acute myocardial infarction.

To ascertain the influence of personality factors on the course of coronary artery disease, we measured Type A behavior in 516 patients within two weeks after an acute myocardial infarction, using the Jenkins Activity Survey questionnaire. Over a follow-up period of one to three years, there was no relation between the Type A score and total mortality, cardiac mortality, time to death for nonsurvivors, left ventricular ejection fraction, or duration of the stay in the coronary care unit. These negative findings were not changed by restricting the analyses to men below 61 years of age or by comparing extreme score categories. The contributions of behavioral, demographic, and cardiac physiologic factors to postinfarction mortality were also evaluated by multivariate survivorship analyses. The physiologic factors were the only ones that contributed a significant and independent mortality risk; the Type A score did not enter the survivorship model (relative risk, 0.8; 95 per cent confidence interval, 0.5 to 1.5). Thus, we found no relation between Type A behavior and the long-term outcome of acute myocardial infarction.

Type A behavior and the thallium stress test.

Several recent studies have examined the association between Type A personality and coronary artery disease (CAD) by coronary angiography. Most of these studies have reported a significant association. The present study is an attempt at further confirmation, using a new non-invasive technique for measuring CAD. Subjects were 53 patients undergoing routine exercise stress tests with concomitant thallium-201 myocardial perfusion studies. Five aspects of Type A behavior were assessed by the use of the Rosenman-Friedman Semistructured Interview, and each was rated on a three-point scale. Severity of CAD was independently estimated on a four-point scale. Pearson correlation coefficients were separately computed for patients with and without reported history of myocardial infarction (MI). For 37 patients without reported MI, CAD severity was significantly correlated with Overall Type A (r = -0.53), Vocal Characteristics (r = -0.53), Job Involvement (r = -0.36) and Aggressiveness (r = -0.48), but not Time Urgency (r = -0.25). For 16 patients with reported MI, CAD severity was significantly correlated with Job Involvement only (r = +0.49). The data are consistent with the association of Type A personality and coronary atherogenesis, but may also reflect Type A psychological and physiological characteristics. Future studies may be able to examine these and other aspects of Type A behavior using this noninvasive technique in more diverse patient populations.

Psychological and behavioral responses after coronary artery bypass surgery.

One hundred consecutive patients who underwent coronary artery bypass surgery at the Columbia-Presbyterian Medical Center from December 1972 through February 1975 were evaluated at surgery and then followed for as long as 4 1/2 years to study their postoperative psychosocial and behavioral course. One patient died during the first 30 days. At 4 1/2 years, 23 patients were reported as deceased, 15 from cardiac causes. The majority of the long-term survivors had substantially less angina and greater exercise capacity; surgery did not increase the number of patients who were employed, but led to substantial improvements in the quality of life, including general pleasure, reduction of anxiety and depression and subjective improvement in job and family roles. Sexual adjustment improved the least; the frequency of sexual relations tended to decrease. Compliance with the medical regimen was relatively good for smoking and exercise, but not for diet or type A behavior, suggesting a need for psychological intervention.

Type A behavior and blood pressure during coronary artery bypass surgery.

Systemic hypertension has been reported as common during coronary artery bypass surgery. The coronary-prone Type A behavior pattern has been associated with heightened reactivity of the sympathetic nervous system. Therefore, the possible relationships between the two was explored. Significant correlations were found between systolic blood pressure rise during surgery and interview ratings of overall Type A (p < 0.05), aggressive content (p < 0.01), and job commitment (p < 0.001). A statistically association was also found between diastolic pressure rise and the job commitment rating (p < 0.01). Significant correlations were still present after controlling for the role of physical predictors of blood pressure rise by statistical multiple regression analysis. The data suggest that patients with Type A behavior characteristics manifest an autonomic hyperactivity which is present under general anesthesia. This hyperactivity may contribute to the association of Type A behavior pattern and coronary heart disease.

The use of the psychiatric consultation record for residency training.

The Psychiatric Consultation Record (PCR) is an instrument developed to aid in the teaching of consultation psychiatry, to evaluate the impact of this teaching, and to provide an overall assessment of the consultation training program at St. Luke's Hospital. The PCR both structures the resident's training experience and provides a tool with which he or she can integrate theoretical and practical knowledge pertaining to consultation work. Its use has enabled supervisors to detect the degree to which didactic material has become integrated into residents' thinking and has provided data through which the scope and quality of each resident's work can be rapidly assessed. Finally, its use has brought to light deficiencies in service delivery which, before the use of this instrument, had not been apparent.

Psychological intervention in coronary heart disease: a review.

Psychological intervention studies designed to reduce cardiac morbidity are reviewed. Preliminary findings suggest that various psychotherapeutic modalities may be effective. Such studies also provide an avenue through which the physical and psychological mechanisms involved in coronary heart disease and their interactions may be clarified. Implications for clinical interventions are also discussed.

Type A behavior pattern and coronary angiographic findings.

One hundred forty-seven consecutive patients scheduled to undergo coronary angiography were classified according to the type-A behavior pattern. Statistically significant correlations were found between diseases severity and the physical risk factors cholesterol, smoking, hypertension, sex, and age. The correlation of the behavior pattern with angiographic disease severity was of the same magnitude as that of the other risk factors except cholesterol, which was greater. The association between the behavior pattern and severity persisted after adjustments had been made for the effects of five other major risk factors.

Delirium after coronary artery bypass surgery.

The incidence of postoperative delirium following coronary artery bypass surgery was 28%. This rate is comparable to that after open-heart surgery. However, of those variables which were previously found to correlate with delirium in the open-heart group, only severity of postoperative illness in the recovery room significantly correlated with delirium in patients having bypass. The relationship between personality type and delirium, previously found to be signficant, was suggestively associated in these patients. A history of myocardial infarction prior to surgery was significantly associated with delirium.