The problem of parental nonadherence in clinical behavior analysis: effective treatment is not enough.

Applied behavior analysts have developed many effective interventions for common childhood problems and have repeatedly demonstrated that childhood behavior responds to properly managed contingencies. The success of these interventions is dependent upon their basic effectiveness, as demonstrated in the literature, their precise delivery by the clinician to the parent, and adherence to or consistent implementation of the intervention. Unfortunately, arranging the consistent implementation of effective parenting strategies is a significant challenge for behavior analysts who work in homes, schools, and outpatient or primary care clinics. Much has been done to address issues of adherence or implementation in the clinic, but relatively little has been done to increase our understanding of the contingencies that affect parental adherence beyond the supervised clinic environment. An analysis of the contingencies that strengthen or weaken adherence might suggest strategies to improve implementation outside the clinic setting. What follows is an analysis of the variables associated with adherence by parents to recommendations designed to solve common childhood problems.

Do children with primary nocturnal enuresis have clinically significant behavior problems?

OBJECTIVE: To determine if primary nocturnal enuresis (PNE) is accompanied by significant behavioral comorbidity. DESIGN: A survey design using a standardized behavioral rating scale. SETTING: Behavioral pediatric clinics in the Midwest. PARTICIPANTS: Subjects with PNE (n=92) were selected from 122 consecutive referrals for enuresis. Criteria included age 5 years or older, PNE status, and wetting frequency of at least once per week. The clinical sample without PNE (n=92) was randomly selected from 429 consecutive referrals to the same pediatric clinics, stratified for age and sex. The nonclinical sample (n=92) was randomly selected by strata from the standardization sample (N=614) of the behavioral checklist used in the study. MAIN OUTCOME MEASURE: The Eyberg Child Behavior Inventory (ECBI), a standardized parent report scale, was used to measure the degree of behavioral comorbidity. The ECBI yields 2 scores, Problem Intensity and Problem Number. RESULTS: Results from 2 separate 3 (group) x 2 (sex) analyses of variance indicated a significant main effect for group on Problem Intensity and Problem Number (P<.001). For Problem Intensity, post hoc comparisons indicated the mean of the PNE sample was significantly higher than the mean of the nonclinical sample (P<.05), but the mean scores of the clinical sample were significantly higher than those of both the PNE and nonclinical samples (P<.05). For Problem Number, post hoc comparisons revealed the means of the PNE and nonclinical samples did not differ from each other (P>.05) but were lower than the mean of the clinical sample (P<.05). CONCLUSION: Primary nocturnal enuresis does not present with significant behavioral comorbidity in most cases. The results suggest that, with the exception of an extraordinary clinical presentation, pediatricians should treat PNE as a common biobehavioral problem without a psychiatric component.

Clinical perspectives in primary nocturnal enuresis.

Primary nocturnal enuresis (PNE) is prevalent among the pediatric population, but not all professionals are aware of the current research regarding the etiology and treatment of this disorder. This paper presents a broad overview of PNE, including etiology and evaluation, with a specific emphasis on treatment issues. The most current treatments (imipramine, desmopressin acetate arginine vasopressin, enuresis alarms) are discussed, including recent research on their effectiveness. In considering the recent data on long-term efficacy, overall cost, and safety, the treatment of choice appears to be the enuresis alarm for those families who are capable of following protocols. Desmopressin acetate arginine vasopressin is a safe alternative that has the advantage of quick response and ease of administration.

Enhancing refusal skills: identifying contexts that place adolescents at risk for unwanted sexual activity.

Refusal skills training is one approach to reducing school-age pregnancy and sexually transmitted disease. The generalization of these skills is dependent, in part, on the relevance to participants of the training scenarios. We identified and cross-validated relevant contexts for inclusion in scenarios for refusal skills training. Fifty-six sexually active female adolescents identified 59 contexts associated with unwanted sexual activity. Fifty-one additional subjects rated these on 9-point Likert scales according to how common and difficult each was for them. Unsupervised activity where alcohol is present or feeling an obligation to engage in sexual activity emerged as high risk contexts. The most common and difficult contexts provide points of departure for the development of relevant training scenarios for refusal skills training, thereby contributing to generalization of these skills and reducing the risk of unwanted sexual activity within this population.

Common obstacles to the daily functioning of pediatric traumatically brain injured patients: perceptions of caregivers and psychologists.

Common difficulties encountered by patients with pediatric traumatic brain injuries (referred to hereafter as pediatric TBI patients) were identified, and the congruence between caregiver and professional perceptions of these problems was examined. Forty-seven caregivers identified 118 obstacles experienced in the care of their pediatric TBI patients. Another sample of 46 caregivers cross-validated these problems by rating each for its frequency and difficulty. Items were tank ordered by their composite score, a derived measure obtained for each item by cross-multiplying the frequency and difficulty ratings. Twenty psychologists who work with pediatric TBI patients also rated each of the 118 problem situations. A modest correlation (tau = .28, p < .001) between the two groups' rank orders of the problem situations, although significant, suggests that there are discrepancies between caregiver and professional perceptions of problem situations. Items perceived as most common and difficult by caregivers often received far lower ratings by psychologists and vice versa. The results suggest that carefully evaluating individual patient concerns may contribute to more efficient use of professional resources and improved patient education and follow-up care.

Psychosocial implications of nocturnal enuresis.

Primary nocturnal enuresis (PNE), a biobehavioral problem affecting approximately 5,000,000 children in the United States, is among the most bothersome and frustrating disorders of childhood. Negative psychosocial consequences are common, secondary to the impact of enuresis on family members and others. The enuretic child may be at increased risk for emotional or even physical abuse from family members and may experience stress related to fear of detection by peers. These factors contribute to the loss of self-esteem that the enuretic child often experiences. Fortunately, a number of treatments--most commonly pharmacologic or behavioral intervention--are often effective in improving or correcting PNE. This disorder not only can be addressed but should be addressed because effective treatment benefits both the patient and the patient's family.

Influence of thumb sucking on peer social acceptance in first-grade children.

Chronic thumb sucking in school-age children may reduce peer social acceptance, an important contributor to social development. The influence of thumb sucking on social acceptance was assessed among 40 first-grade children, who were shown four slides of two 7-year-old children (one boy, one girl) in two poses (one thumb sucking, one not). After viewing each slide in their classrooms, the children answered 10 numerically weighted questions related to peer acceptance. To limit the possibility that the children would determine the girl and boy were the same in each pose, the slide presentation was counterbalanced across two sessions 1 week apart. Using a repeated-measures analysis of variance, the authors compared composite scores on each question for both poses. The results indicate that while in the thumb-sucking pose, the children were rated as significantly less intelligent, happy, attractive, likeable, and fun and less desirable as a friend, playmate, seatmate, classmate, and neighbor than when they were in the non-thumb-sucking pose. These findings suggest that the risk of reduced social acceptance should be added to the list of potentially harmful effects of chronic thumb sucking in school-age children.

Parental versus professional perceptions of obstacles to pediatric diabetes care.

Parents of children with insulin-dependent diabetes mellitus (IDDM) (n = 38) were surveyed to identify common and difficult obstacles to diabetes care. A list of these obstacles was cross-validated by a second parent sample (n = 47) who rated each item according to how common and difficult each item was for them. The list then was rated by a sample of diabetes professionals (n = 15) to evaluate the extent of agreement between parents and health care professionals regarding the frequency with which these obstacles occur and the difficulty they pose to everyday diabetes care. Professionals disagreed with parents regarding which obstacles were most common and difficult, generally rating problems as significantly more common and difficult (t = 5.20, P = < .001) than did the parents who experienced them. The results of the survey underscore the importance of health care providers evaluating the concerns of the local patient community when developing educational and treatment services for these patients.

Parental and professional perceptions of problems associated with long-term pediatric home tube feeding.

We surveyed 24 caregivers of children fed by gastrostomy tube to identify day-to-day problems encountered in home enteral nutrition. In a second survey, 21 respondents cross-validated the problem list by rating how often they experienced each problem and how difficult each problem was to manage. Problems related to social functioning, recreational activities, and family functioning were rated by caregivers as the most frequent and difficult. We asked 11 pediatric feeding specialists to rate the same problems based on their perceptions of the frequency and severity of problems experienced by caregivers. Moderate agreement was found between professional and caregiver ratings, although professionals generally rated problems as more common and difficult than did the caregivers. Additionally, positive relationships were found between caregiver ratings of common gastrostomy-tube problems and general levels of stress in the home. Data suggest that problems identified by caregivers as most common and difficult are often in the social rather than the medical realm. A broadly based family assessment that focuses on medical and social aspects of home enteral nutrition may maximize nutritional benefits for the patient as well as improve general family functioning and reduce stress in the home.

Acute and chronic effects of hypoglycemia on cognitive and psychomotor performance.

The acute and chronic effects of hypoglycemia on cognitive and psychomotor performance are reviewed. Studies involving pediatric and adult subjects, both with and without diabetes were evaluated. The preponderance of studies suggest that hypoglycemia can be an unintended yet frequent result of treatment of patients with IDDM. Significant cognitive and psychomotor deficits were reported even with mild episodes of hypoglycemia. Early age of diabetes onset and frequent episodes of hypoglycemia were found to be highly related to significant deficits in intellectual and academic performance. Patients evidencing performance deficits did not always report symptoms of hypoglycemia. Recovery of cognitive functioning lagged restoration of euglycemia but typically returned to baseline levels of performance. Recommendations for improved patient care are provided.

Developing anxiety-reduction procedures for a ventilator-dependent pediatric patient.

This study evaluated two strategies to reduce anxiety behaviors which interfered with the daily tracheostomy care and ventilator maintenance of an eight-year-old ventilator-dependent boy. A multiple-baseline design (across ventilator and tracheostomy procedures) was used to evaluate the effectiveness of an information-only procedure and combined relaxation and cognitive distraction procedures. Partial-interval recording was used to measure heart rate, disruptive mouth noises, and demands and complaints to staff members. The patient's behavior did not change during a no-intervention baseline or during the information-only condition. Cognitive distraction and relaxation procedures were introduced, first during ventilator checks and then during tracheostomy care; corresponding decreases in heart rate, mouth noises, and demands and complaints were noted. Gains were maintained at one year follow-up. Results suggest that information alone may not effectively reduce anxiety behaviors for some ventilator-dependent patients unless additional anxiety-reduction procedures are implemented.

Teaching refusal skills to sexually active adolescents.

Refusal skills training was extended to sexually active handicapped female adolescents who lacked an effective refusal strategy. Role-plays for assessment and training were developed using the who, what, when and where of situations which resulted in unwanted intercourse. Refusal skills were trained following the format of rationale, modeling, rehearsal, feedback, and reinforcement. Baseline rates of most target behaviors were quite low. High frequencies of target behaviors were observed as each behavior became the focus of training. Generalization across staff and time was also observed. The skillfulness and effectiveness of the subjects' refusal skills were judged to be improved as a function of training. One-year follow-up showed decreased sexual activity for each girl.

PIP: In an attempt to curtail adolescent pregnancy, refusal skills were taught to 2 sexually active and handicapped female adolescents. The goal was to surpass the just say no philosophy by 1) socially validating each girl's effectiveness and skill, and 2) extending refusal skills training to special populations, where skill deficits may be more prevalent and the need the greatest. One child Amy, 16 years) was dead and was being treated for sexual disorders, and the other (Karen, 14 years) was developmentally delayed and sexually precocious. Both desired refusal skills. Training was designed to teach skills to effectively refuse sexual advances when they deemed it necessary and desirable to do so. An assessment was made for each girl. A role play vignette was developed for each girl which relied on her past experiences. The performance of the role play was videotaped in order to identify the particular deficits in refusal assertion. Refusal, specification, leaving the situation, and eye contact were situations that were categorized as either an occurrence or nonoccurrence for the pre- and postassessments. Skills were taught based on rationale, feedback, modeling, behavioral rehearsal, and reinforcement. 8 randomly ordered play roles were analyzed by 2 observers to evaluate social perception of client refusal skills and effectiveness. Reliability was evaluated using Cohen's Kappa (K). The K for eye contact was .84; refusal , .85; leaving the situation, 1.0; and specifying objectionable behavior, .90. The deaf child, Amy, initially showed only eye contact skills, while Karen used only verbal refusal before skills training. The intervention created long and shortterm effects, i.e., use of target behaviors posttraining, at a 2-week follow up with nonintervention staff, and a 1-year telephone follow up which indicated decreased sexual activity for each girl. Significant differences were found in the baseline and posttreatment performance ratings for both refusal and effectiveness (F=103.02, df=27.3, p=.001; and F=243.7, df=27.3, p.001). For Karen only refusal skill rating was significantly changed (F=22.06, df=27.3, p=.001). There is a need to provide additional research to verify the actual effectiveness of refusal skills packages and their impact on the occurrences of unwanted sexual behavior. Refusal components, developmental factors, societal norms, familial and peer pressure that are most critical need to be determined. Generalizability is limited.

Nocturnal enuresis: a prevalent, persistent, yet curable parasomnia.

Nocturnal enuresis is a common, largely inherited condition wherein children involuntarily pass urine while asleep. What is inherited appears to be a mild maturational delay that expresses itself partly in terms of growth and development and primarily in terms of diminished urinary control. Drugs are the most frequently used treatment but the recent literature shows that they are inappropriate as a primary treatment because of potential risks to child health and/or questionable long-term effectiveness. Effective treatment requires the specific teaching of continence skills, and several behavioral methods suitable to that purpose are described in this paper.

Behavioral rehabilitation of functional alexia.

A 10-year-old boy with a functional reading deficit (i.e. functional alexia) was successfully treated with hospital based escape/avoidance procedures. A multiple baseline design was used to evaluate the effectiveness of treatment. Generalization of treatment effects across individuals, settings and time was demonstrated. Extension of these procedures to other functional deficits is discussed.

Social skills and irrational beliefs: a preliminary report.

Recent studies have suggested that irrational beliefs, as measured by the Irrational Beliefs Test (IBT), may contribute to social skills deficits. However, studies evaluating the correspondence between irrational beliefs and behavioral indices of social skills and social anxiety have yet to be reported. IBT data obtained from social skill deficit patient populations also have yet to appear in the literature. The present study addresses these issues by presenting IBT data obtained from a sample of 63 psychiatric patients referred for assessment of social skills deficits and evaluating the relationship of these data and patients' performance on a standardized behavioral measure of social skills and social anxiety, the Simulated Social Interaction Test (SSIT); and, presenting a comparison between IBT subscale scores obtained from the psychiatric sample and those obtained from a large (n = 897) student sample. A weak relationship was found between two IBT subscales and the SSIT. A mean level difference between patients' performance and student norms was also found on four subscales of the IBT. Implications for further assessment and treatment research with the IBT, social anxiety and social skills are discussed.

Peer instruction of home glucose monitoring.

During a 2-wk summer camp for insulin-dependent children aged 9-15 yr, a voluntary program of home glucose monitoring using an Ames' Dextrometer was offered. The primary instructors were campers who had mastered the procedure and who, with limited staff assistance, tutored naive campers. By camp's end, 96% of all naive campers had practiced this new home glucose monitoring procedure. Procedural errors were infrequent and decreased as a function of practice. No significant differences were found in error rates as a function of either the age or sex of the user. The data suggest that home glucose monitoring could be incorporated into the treatment regimen of many young patients and that peer instruction is an effective method of introducing the procedure to young children.

Stimulus stringing by pigeons.

Pigeons were trained to peck one, two, three, and then four colors in a predetermined sequence from a five-key array where, over trials, each color appeared equally often in each position of the array. Incorrect pecks resulted in a buzzer and trial termination, with the same array presented for the next trial. Correct pecks produced feedback and correct strings could produce food. All subjects performed at a high level of accuracy with no difference at asymptote between a continuous and a mixed spectral sequence as the required order. Transfer to a new set of arrays had little effect on accuracy. Errors forward in the sequence had the highest probability, followed by repeat errors, backward errors, and dark-key errors. Some arrays had a higher level of accuracy than others but a corresponding systematic variable could not be identified.