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Exercising choice for national healthcare. In the end, we'll get what we choose.

Whether we evolve toward a market model, a play-or-pay model, or a national model will depend largely upon our personal beliefs and perspectives. Unfortunately, in the hectic and fast-paced life that virtually all of us lead, we base many of our conclusions on unexamined bits and pieces of conventional wisdom. We have looked at but five of them. Yet these bits and pieces become the yardsticks by which we measure other plans and other people. Instead of listening to and studying the approaches proposed by others, we are often too quick to dismiss them with labels such as "too costly," or "too capitalist," or "too socialist," or "too whatever." As a consequence, we become prisoners of our own ideology. Would that we were more like Tillich's (1951) description of the famous theologian, Karl Barth, who "...strenuously tries not to become his own follower" (5). In other words, we would work to continually inform and correct ourselves in light of new understanding. Our healthcare problems--any social problems, for that matter--are never really solved. All we can do is do our best at meeting needs, even if it means that in meeting one set of needs we inadvertently create other needs. But that is why we are enriched when we accept the challenge of continuing to question our personal bits and pieces of conventional wisdom. In a recent column in the Houston Post, Richard Reeves cites statistical evidence, known to most who work in the healing professions, indicating that people who live alone tend to suffer from greater illness.(ABSTRACT TRUNCATED AT 250 WORDS)

Decision Making↗

Social problem-solving and vulnerability to depression in a clinical sample.

The relationship between problem-solving and depression was examined in a sample of 48 new clients (38 women and 10 men) presenting at three Community Health Centers over a 3-wk. period. The clients were predominantly Anglosaxon and ranged in age from 19 to 59 years. At the time of admission each client completed a questionnaire including the Beck Depression Inventory-Version II, the Inventory to Diagnose Depression, and the Social Problem-solving Inventory-Revised. The first two inventories were used to identify a currently depressed group, a previously depressed group, and a never depressed group. Consistent with past research, currently depressed clients had lower scores on all dimensions of social problem-solving than did nondepressed clients. In contrast, clients who reported a past episode of depression but who were not currently depressed did not differ from those nondepressed clients who had no history of depression. The data suggest that the deficit in social problem-solving evident in depression may be a concomitant of the person's current mood rather than an underlying vulnerability factor. However, further investigation into changes in problem-solving over time and the correspondence of self-reports of problem-solving to more objective measures of skill is warranted.

Adolescent↗

Caregiver depression following traumatic brain injury (TBI): a consequence of adverse effects on family members?

Many studies have demonstrated that the behaviour of individuals with traumatic brain injury (TBI) predicts the emotional adjustment of their caregivers. The primary objective of the present study was to obtain an understanding of potential moderating and mediating variables between carer depression and analogous stressors. Seven sets of predictor variables (demographic variables, concurrent stressful life events, behavioural problems, social role problems, extent of adverse effects on family members, appraisal, and support) and the criterion variable of depression in caregivers were examined. Fifty-eight carers participated in the study at 6 months, 1 year, 2 years, or 3 years following injury. The number of adverse effects on family members (other than the informant) was the only stressor significantly related to carer depression. However, carer appraisal of adverse family effects was found to mediate the relationship between stressor and depression, and carer perception of support effectiveness was found to moderate the effect of adverse family effects on depression. Forty-six per cent of the variance in caregiver depression was accounted for by carers appraisal of adverse family effects and the interaction of adverse family effects and support effectiveness. These findings highlight the importance of supporting families as a whole in the rehabilitation of persons with TBI.

Activities of Daily Living↗

Disabled persons in Poland.

It is generally considered that disability is an important social problem. This was expressed for example by the decision of the United Nations Organisation to nominate 1981 as the International Year of the Disabled. The number of disabled is one of the main problems. For social planning, the proper allocation of goods and resources for changes in the attitudes of society towards disability it is necessary to identify the prevalence, distribution and composition of the disabled. Prior to the 1978 Census, in Poland there was no information available on disability except the number of disabled persons legally classified by the Medical Board for Disability and Employment receiving disability pension, as well as the average amount of such pension, the number of disability certificates issued annually, the number of employed and the number employed in co-operatives for the disabled. The social criterion--major social role associated with psycho-physical state--was the main concept of the investigation on the frequency of disability in 1978 Census. Methodology used in this study of disability was based on the U.S. experience gained from the 1970 NC, as well as on the NCHS Survey of psychophysical causes of permanent limitation of social role performance and locomotion, performed since 1957. It should be explained, however, that the scope of disability investigated in NCHS Survey and in Polish Census is exactly the same and much wider than in U.S. Censuses. The Polish National Census revealed that there are 2,485,001 disabled persons in Poland, i.e. 7.1% of the total population. The urban population constituted 57.7% and the inhabitants of rural areas 42.5% of the total population.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

Impairment, disability and handicap in chronic respiratory illness.

Chronic obstructive airways disease (COAD) is a major, though neglected, medical and social problem in the United Kingdom today. Dyspnoea is one of the most distressing and disabling symptoms of COAD, which is itself the largest single cause of absence from work in the United Kingdom. 92 patients suffering from COAD were interviewed in order to assess impairment, disability and handicap. Measures included spirometric tests of lung function; the Fletcher breathlessness grading scale, the oxygen cost diagram and a visual analogue scale of dyspnoea; the Functional Limitations Profile (FLP); and the shortened 12 item General Health Questionnaire (GHQ-12), supplemented by the 7-item GHQ sub-scales of anxiety and severe depression. Low correlations were found between lung function and disability (-0.38, P less than 0.001), accounting for only 14% of the variance, and high correlations were found to exist between measures of dyspnoea and disability (-0.90, P less than 0.001). Major areas of disability and handicap included; household management, ambulation, sleep and rest, recreation and pastimes and work. Financial problems and difficulties, housing problems and problems of social isolation were also frequently reported. The paper goes on to discuss both the need for a more integrated approach to the care and rehabilitation of COAD patients and their families and for a complementary social perspective and approach to COAD and its treatment.

Persons with Disabilities↗

Cognitive and clinical predictors of success in vocational rehabilitation in schizophrenia.

Cognitive impairments in schizophrenia appear to be associated with social problem solving, social and vocational functioning, and psychosocial skill acquisition. The present study examined the relationship of cognitive functioning, as well as clinical symptoms, to vocational outcomes among individuals with schizophrenia. One hundred and twelve participants with DSM-IV schizophrenia spectrum diagnoses underwent a comprehensive neuropsychiatric evaluation after enrolling in one of several employment programs. The neuropsychological evaluation examined verbal learning and memory, attention, speed of information processing, and executive functioning. Clinical symptoms were evaluated with the Positive and Negative Syndrome Scale (PANSS). Vocational outcomes were assessed 4 months after baseline assessment and included both measures of employment outcome (e.g., earnings) and of work performance as assessed by the Work Behavior Inventory (WBI). Negative symptoms, learning and memory performance, processing speed, and executive functioning were related to hours, weeks, and wages earned on the job. Stepwise multiple regression analyses found that among baseline clinical and cognitive predictors, only verbal learning and memory and cognitive disorganization symptoms were significant predictors of work behaviors 4 months later. Learning and memory were the only significant predictors of integrated employment at 4 months. These results suggest specific aspects of cognition may be modestly predictive of vocational outcomes.

Achievement↗

A new interview for the multiaxial assessment of psychiatric morbidity in medical settings.

A new semistructured instrument, the Standardized Polyvalent Psychiatric Interview or SPPI has been developed primarily for assessing medical patients. It has been built on the Clinical Interview Schedule and is intended to evaluate individuals in a multiaxial schema: psychopathology, including duration and severity of disorder; somatic disturbance; social problems and social supports: and pre-morbid personality, with special emphasis on 'neuroticism'. The SPPI generates enough information to allow the use of different research diagnostic criteria, including DSM-III-R, ICD-10 and Goldberg's criteria of 'attribution' of somatic symptoms and 'relationships between psychiatric and physical disorder'. It also includes a section related to recommended treatment. The new interview fulfils standards of feasibility, face and content validity. An incomplete block design, inter-rater reliability study was carried out with a consecutive sample of 48 out-patients referred to the Psychosomatic-Liaison Service of the University Hospital of Zaragoza. A broad range of agreement coefficients were calculated, the results being quite acceptable (most kappas are in the range from 0.7 to 0.9) and tending to support the procedural validity of the interview.

Adolescent↗

Bulimia nervosa: a 5-year follow-up study.

Fifty patients with bulimia nervosa were followed up for a minimum length of 5 years. Standardized interviews, observer-rated instruments and self-rated questionnaires were employed both at entry and at completion of the follow-up period. After tracing, the positive response rate was 72%; one patient had died. At the time of follow-up 31% of those traced had made a complete recovery and 25% still fulfilled diagnostic criteria for bulimia nervosa. Judged on behavioural symptoms 47.2% of responders had a 'good' outcome. Good outcome was associated with fewer social problems, higher social class, and a significant improvement in eating attitudes at follow-up. All outcome groups reported a reduction of interference by symptoms in other areas of life, and an improvement in mood state. No factors, including those described in previous studies, were identified which predicted outcome.

Adolescent↗

Emotion knowledge in economically disadvantaged children: self-regulatory antecedents and relations to social difficulties and withdrawal.

We examined the relations of verbal ability and self-regulation in preschool to emotion knowledge in first grade, and concurrent relations between emotion knowledge and indexes of social functioning in 143 children from low-income families. After controlling for children's verbal ability in preschool, teacher reports of attentional control and caregiver reports of behavioral control in preschool predicted children's emotion expression knowledge and emotion situation knowledge 2 years later. After controlling for verbal ability and attentional and behavioral control, children's emotion knowledge predicted concurrent teacher-reported social problems and social withdrawal. Results suggest that low levels of emotion knowledge co-occur with many important aspects of children's early social adaptation.

Adaptation, Psychological↗

The effect of virtual reality cognitive training for attention enhancement.

Our main goal in this research was to validate the possibility of virtual reality (VR) for attention enhancement in cognitive training program. Then, we developed some cognitive training tasks using VR technology. Thirty subjects who had little behavioral problems and social problems were randomly assigned into three groups: VR group, non-VR group, and control group. Only the VR group used the head-mounted display (HMD) and position sensor. While the VR group and non-VR group performed cognitive training, the control group received no special treatment. All participants took their eight session tasks over 2 weeks. Participants executed a continuous performance task (CPT) before and after training sessions. We found that immersive VR with cognitive training is effective for attention enhancement. Also, we confirmed that our cognitive training can improve the attention span of children and adolescents with behavioral problems and help them learn to focus on some tasks.

Adolescent↗

Psychopathology in children with epilepsy: a meta-analysis.

OBJECTIVE: To examine the types and severity of psychopathology in children with epilepsy. METHODS: A series of meta-analyses were conducted to review 46 studies, including 2,434 children with epilepsy. RESULTS: Effect sizes were medium to large for comparisons with children from the general population, which indicates that children with epilepsy are at increased risk for psychopathology, including internalizing and externalizing behavior problems. Comparisons with children with another chronic illness revealed small to medium effect sizes, indicating that psychopathology in children with epilepsy may partly be attributed to chronicity of the disease. Attention problems, thought problems, and social problems proved to be relatively specific to epilepsy. Comparisons with siblings suggested that psychopathology in children with epilepsy may be associated with family factors, especially where behavioral disorders appear to be more generic. CONCLUSIONS: Clinicians should consider both neurological and psychosocial factors, including the family system, when treating psychopathology in children with epilepsy.

Child↗

A pilot study on the effectiveness of tele-analogy-based problem-solving training for people with brain injuries.

People with brain injuries must often deal with cognitive problems, including social problem solving. The present study evaluated the effectiveness of a 20-session, online, interactive, skill-training programme on the solving of problems using analogies. It was hypothesized that the programme could help people with brain injuries learn better problem-solving skills through systematic, theoretically driven learning strategies. Fifteen Hong Kong-Chinese with brain injuries participated in this pilot study. They were randomly assigned to an online programme, a computer-assisted programme or a therapist-administered programme. The three programmes had a similar structure and contents, including basic components problem solving, reflective sessions and functional problem solving. Outcome measures included the Category Test of Halstead-Reitan Test Battery, and a daily problem-solving performance and self-efficacy checklist. The results showed that the subjects of the three programmes generally demonstrated higher post-training self-efficacy and basic problem-solving skills. The group using the online programme, however, showed better and quicker improvements in problem-solving performance, and demonstrated a general trend towards making fewer errors in complex problem-solving tasks. In conclusion, people with brain injuries can use the successful problem-solving experiences obtained in the training programmes with different delivery modes to solve daily living problems that are similar in nature. However, the generalizability of the effects of the programme is still to be determined.

Adolescent↗

Biogenetic temperament and character and attention deficit hyperactivity disorder in Korean children.

BACKGROUND: The objective of this study was to evaluate the relationship between symptoms of attention deficit hyperactivity disorder (ADHD) and biogenetic temperament, as assessed by the Junior Temperament and Character Inventory (JTCI) in Korean elementary school children. SAMPLING AND METHODS: Five hundred and sixteen elementary school students (254 boys and 262 girls; age range 9-14 years, mean age 11.0 +/- 1.0 years) were studied. The Junior Temperament and Character Inventory, both the self-rating and parent rating scales, the DuPaul ADHD rating scale (ARS-IV) for parents and teachers and the Child Behavior Checklist have been completed by study subjects. Children with high ARS-IV scores (the upper 10th percentile, n = 52) were defined to have ADHD. Fifty-two age- and sex-matched non-ADHD control subjects were selected randomly from a pool of 464 subjects. RESULTS: Inattention and hyperactivity/impulsivity symptoms correlated positively with Novelty Seeking in both children and parent ratings. These symptoms correlated negatively with Persistence, Self-Directedness and Cooperativeness. Novelty Seeking also had significant correlations with attention problems, delinquent behavior, aggressive behavior, externalizing problems and social problems in the Child Behavior Checklist. The ADHD group (n = 52) had higher scores of Novelty Seeking and lower scores of Self-Directedness and Cooperativeness, compared with the control group. CONCLUSIONS: There were significant correlations between ADHD symptoms and Novelty Seeking. Current findings suggest that Novelty Seeking and ADHD share biogenetic backgrounds.

Adolescent↗

Economic burden of drug dependency. Social costs incurred by drug users at intake to the National Treatment Outcome Research Study.

BACKGROUND: The use of illegal drugs is seen as a major social problem. The social costs can be high. METHODS: Self-report data from interviews at intake to the National Treatment Outcome Research Study (NTORS) for 1075 drug users and cost data from various sources were used to estimate criminal behaviour and health and addiction service costs for a 12-month period. Multivariate statistical analysis was used to analyse cost variations. RESULTS: Total costs for one year for the drug users amounted to over 12 million Pounds, the majority attributable to self-reported criminal behaviour. Social costs were positively related to a variety of factors including instability in living circumstances, amount of heroin used and whether or not drugs were taken intravenously. CONCLUSIONS: The study clearly demonstrates the economic and social burden associated with heavy drug users and highlights the need for further investigations into the costs and benefits of policies that can reduce these social costs.

Age Factors↗

Predictors of psychopathology in young adults referred to mental health services in childhood or adolescence.

BACKGROUND: For children referred to mental health services future functioning may be hampered. AIMS: To examine stability and prediction of behavioural and emotional problems from childhood into adulthood. METHOD: A referred sample (n = 789) aged 4-18 years was followed up after a mean of 10.5 years. Scores derived from the Child Behavior Checklist, Youth Self-Report and Teacher Report Form were related to equivalent scores for young adults from the Young Adult Self-Report and Young Adult Behavior Checklist. RESULTS: Correlations between first contact (T1) and follow-up (T2) scores were 0.12-0.53. Young adult psychopathology was predicted by corresponding T1 problem scores. Social problems and anxious/depressed scores were predictors of general problem behaviour. CONCLUSIONS: Problem behaviour of children and adolescents referred to outpatient mental health services is highly predictive of similar problem behaviour at young adulthood. Stability is higher for externalizing than for internalizing behaviour and for intra-informant than for inter-informant information. Stabilities are similar across gender. To obtain a comprehensive picture of the young adult's functioning, information from related adults may prove valuable.

Adolescent↗

Variable-time reinforcement schedules in the treatment of socially maintained problem behavior.

Noncontingent reinforcement (NCR) consists of delivering a reinforcer on a time-based schedule, independent of responding. Studies evaluating the effectiveness of NCR as treatment for problem behavior have used fixed-time (FT) schedules of reinforcement. In this study, the efficacy of NCR with variable-time (VT) schedules was evaluated by comparing the effects of VT and FT reinforcement schedules with 2 individuals who engaged in problem behavior maintained by positive reinforcement. Both FT and VT schedules were effective in reducing problem behavior. These findings suggest that VT schedules can be used to treat problem behavior maintained by social consequences.

Adolescent↗

'Breathtaking': the consequences of chronic respiratory disorder.

Chronic obstructive airways disease (COAD) is a major, though neglected, medical and social problem in the United Kingdom today. Dyspnoea is one of the most distressing and disabling symptoms of COAD, which is itself the largest single cause of absence from work in the United Kingdom. This paper reports on 92 patients suffering from COAD, who were interviewed in order to assess impairment, disability and handicap, and a smaller subsample of 24 of these patients who were followed-up using open-ended, semi-structured, tape-recorded interviews in order to cover in more detail some of the issues raised in the first quantitative stage of the study. Low correlations were found between lung function and disability (-0.38 p less than 0.001), accounting for only 14% of the variance, and high correlations between measures of dyspnoea and disability (-0.90 p less than 0.001). Major areas of disability and handicap included: household management, ambulation, sleep and rest, recreation and pastimes, and work. Financial problems and difficulties, housing problems and problems of social isolation were also frequently reported. The paper then attempts to explore the relationship between impairment, disability and handicap, drawing on both the quantitative and qualitative data collected in order to illustrate the variable nature of this relationship. The paper concludes by suggesting both the need for a more integrated approach to the care and rehabilitation of COAD patients and their families, and for a complementary social perspective and approach to COAD and its treatment.

Activities of Daily Living↗

Main problems of modern medicine in diagnostics and learning: ways of optimal solution.

OBJECTIVE: 1. Selecting the key problems in medicine--I. Diagnostic problems, II. Didactic and training problems of medical education, III. Economical problems, IV. Communications technologies problems, V. Psychological problems, VI. Social problems, VII. Strategic problems. 2. Outline ways to optimal solution of these problems. METHODS: Innovative intellectual approach to medical diagnostic decision-making has been suggested. Knowledge levels and didactic systems, its limitations have been described. The methodologies and computerized technologies are tools to overcome the obstacles. RESULTS: Series of didactic experiments were carried out with the purpose to evaluate comparatively conventional and offered innovative methods of diagnostics and professional training shows significant advantages of the innovations. CONCLUSION: The above mentioned problems can be solved successfully by computerized diagnostics based on algorithmical evidence-based approach to disease recognizing, and mass professional education mainly based on eLearning.

Algorithms↗