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Facilitated communication: the effects of facilitator knowledge and level of assistance on output.

Investigated facilitated communication with 10 adults with autism, and specifically examined the effects of facilitator influence and level of assistance as a function of facilitator knowledge of experimental stimuli. Six men and four women with autism served as subjects, ranging in age from 14 years to 51 years of age. Each subject had 6 experimental sessions, 2 with no help, 2 with partial assistance, and 2 with full assistance. Within each session, the facilitator had knowledge of the experimental stimuli in one half of the trials. Results revealed no cases of correct responding independent of facilitator knowledge of correct answers. Additionally, facilitator control was apparent in numerous cases in which typed output matched stimuli to which the facilitator, not the subject, had been exposed. Results suggest that clinical and educational use of the procedure should be curtailed pending further experimental investigation.

Adolescent↗

An enquiry into scientific and media discourse in the MMR controversy: authority and factuality.

In this paper, we investigate two scientific articles at opposite ends of the MMR debate-Wakefield et al. (1998) (which started the debate) and Taylor et al. (1999)-and four media articles published to inform the public of the results of these two scientific studies. Because people need to assess truth claims about health risks, communicators seek to establish their believability in two ways: authority (i.e., the attribution of scientific claims to sources that may be perceived as believable because of their status) and factuality (i.e., the moderating, limiting, or highlighting of truth claims). The importance of authority was confirmed by the media texts' preference for direct quotes and messages about what people ought to do, especially at the beginning of the debate. Our most significant find, however, relates to two important indicators of factuality: avoidance of vague references and high use of epistemic modals, where Wakefield et al. displays a pattern not at all different from the media texts and opposite to that expected from a scientific text. That Wakefield et al. stands out in the majority of indicators investigated is of interest in view of its controversial position in the MMR debate and worthy of further study.

Autistic Disorder↗

Family process and child anxiety and aggression: an observational analysis.

Barrett, Rapee, Dadds, and Ryan (1996) described a phenomenon whereby family discussions magnified the style of children's problem solving in a way characteristic of their particular clinical diagnosis. That is, anxious children became more avoidant, aggressive children more aggressive, and nonclinic children more prosocial, after discussing ambiguous hypothetical situations with their parents. This study examined specific sequences of communications exchanged between parents and children hypothesized to underlie this family exacerbation of child cognitive style. Family discussions were videotaped and categorized for groups of anxious, aggressive, and nonclinic children and their parents. Results revealed differences between groups of parents in frequency of agreeing with and listening to their child and the frequency of pointing out positive consequences. Conditional probability analyses showed that parents of anxious children were more likely to reciprocate avoidance, while parents of nonclinic children were more likely to agree with and listen to prosocial plans from their child. Differences in parent behaviors observed during the family discussions were reliably associated with the child's response to the ambiguous situation proposed after the family discussion. Results support a model of developmental anxiety and aggression that emphasizes the interaction of family processes and social-cognitive development in the child.

Adolescent↗

Recognising pain in older adults living in sheltered accommodation: the views of nurses and older adults.

Sixty-six randomly selected older adults and their contact nurses participated in interviews based on standardised assessments of pain and open-ended questions focusing how pain was expressed and recognised. The sample included older adults with normal as well as cognitively impaired function. Seventy-nine percent of older adults with normal cognition were often in pain. Contact nurses assessed pain in 57% of cognitively impaired older adults. The content in the statements showed that pain recognition was a communicative interactive process based on verbal and non-verbal expressions. The process comprised attempts to understand the cause and intention of the expression and to verify the presence of pain. Changes in mood, facial expressions and physiological responses were described less often by older adults than by their nurses. Contact nurses of cognitively impaired older adults judged immobility as the source of pain, that it was possible to see when the person was in pain and that pain was expressed by paralinguistic and body language more often than contact nurses of cognitively healthy older adults. Characteristics of nurses and older adults could facilitate or hinder pain recognition. The findings indicate a need for reflective discussions in the staff group focusing on how to perform systematic assessments of verbal and non-verbal expressions and of hindrances and facilitators for recognising pain in older adults.

Adult↗

Increase in RANKL: OPG ratio in synovia of patients with temporomandibular joint disorder.

Although a recent study suggested the involvement of RANKL and osteoprotegerin (OPG) in the pathogenesis of bone-destructive disease, no study has focused on the RANKL:OPG ratio in the synovial fluid of patients with temporomandibular joint (TMJ) disorder. This communication reports on the concentrations of RANKL and OPG in synovial fluid from TMJ patients and healthy control individuals. In contrast to an unchanged concentration of RANKL, a strong decrease in the concentration of OPG was detected in the synovial fluid from patients with TMJ internal derangement. Treatment with the synovial fluid of osteoarthritis (OA) patients resulted in the high production of osteoclast-like cells from blood mononuclear cells in vitro, as well as in pit formation in dentin slices. The addition of anti-RANKL IgG or OPG attenuated OA-synovial fluid-induced osteoclast formation, suggesting that the increase in the RANKL:OPG ratio in the microenvironment of the joint has the potential to induce osteoclastogenesis in TMJ osteoarthritis.

Adult↗

The relationship between parental communication deviance and relapse in schizophrenic patients in the 1-year period after hospital discharge. A pilot study.

The present pilot study examined the ability of parental communication deviance (CD) to predict relapse in schizophrenic patients in the 1-year period after hospital discharge. Measures of CD were obtained from verbatim transcripts of family problem-solving discussions for 20 schizophrenic patients and their parents at an initial assessment and before the patients' hospital discharge. Relapse was assessed using the Brief Psychiatric Rating Scale at 3-month intervals after discharge. Findings indicated that parental CD measured at an assessment immediately before the patient's release from the hospital was moderately correlated (r = .49, p < .05) with relapse in the 1-year follow-up period. Results are discussed with respect to the possible role of parental CD as an environmental stressor in the period after discharge. Potential contributors to parental CD, including genetically transmitted cognitive deficits and stress resulting from resuming the care-giver role, are also discussed.

Adult↗

The evaluation of acute pain in individuals with cognitive impairment: a differential effect of the level of impairment.

The present study investigated whether the level of cognitive impairment (CI) affects acute pain behavior and how it is manifested. Participants were 159 individuals (mean age 42+/-12), 121 with CI (divided into four groups according to the level of CI: mild, moderate, severe, profound) and 38 with normal cognition (controls). The behavior of the participants before and during acute pain (influenza vaccination) was coded by two raters with the Facial Action Coding System (FACS - scores facial reactions to pain) and the Non-Communicating Children's Pain Checklist (NCCPC-R - scores both facial and general body reactions). Individuals with severe-profound CI exhibited elevated FACS and NCCPC-R values at baseline compared with all other groups (p<0.01). Both FACS and NCCPC-R scores of individuals with mild-moderate CI and controls increased significantly during vaccination (p<0.001). In contrast, individuals with severe-profound CI exhibited high rates of "freezing reaction" (stillness) during vaccination, manifested mainly in the face and therefore resulting in elevation of only NCCPC-R scores but not of FACS's. The results suggest that the level of CI affects baseline as well as pain behavior and it is therefore necessary to choose an appropriate behavioral tool to measure pain in these individuals accordingly. For example, tools based on facial reactions alone might provide the false impression that individuals with severe-profound CI are insensitive to pain (due to freezing).

Acute Disease↗

Interrelations among social-cognitive skills in young children with autism.

Typically developing infants show a reliable developmental sequence of emergence of early social-cognitive skills, such as joint attention, communicative gestures, gaze and point following, imitation, and referential language. First infants share others' attention, then they follow others' attention and then behavior, and then they direct others' attention and then behavior. The current study used a series of tests from a study of typically developing infants (Carpenter, Nagell, & Tomasello, 1998) to investigate interrelations among these social-cognitive skills in young children with autism and children with other developmental delays. Tests of object permanence, spatial relations, facial and manual imitation, and executive function also were included. We found that for most children with autism, unlike other children, tests involving others' attention were more difficult than tests involving others' behavior. However, within the domains of attention and behavior, the typical pattern of sharing, then following, and then directing was evident. There were several positive intercorrelations among the social-cognitive skills (as there were for typically developing infants), but there also was some evidence of individual differences in patterns. Implications for theories of social-cognitive and language development are discussed.

Autistic Disorder↗

Development of a screening instrument for language in older people (Barnes Language Assessment).

Language changes are associated with several types of age-related degenerative processes and are known to be particularly stressful for carers. Managing language and communication difficulties in older people has been shown to be an important aspect of dementia care. A test such as the one described here, might be a useful tool for health professionals planning care for older people with possible diagnoses of dementia. The information gained could be used as part of multi-disciplinary team assessment. This paper describes the development of a clinically viable assessment tool for the assessment of language and associated cognitive skills in the older population. Data on 43 normal older people were used to establish preliminary means and lower normal limits, as a guide to distinguishing performance associated with normal age-related change from performance associated with pathology. In the next phase data was collected from 43 older people with possible dementia who were attending clinics and hospital departments. The results suggest that the Barnes Language Assessment can profile language skills and difficulties and may be a useful diagnostic tool to contribute to language assessment of older people. Indications for further research are discussed.

Aged↗

Psychometric properties of the non-communicating children's pain checklist-revised.

The non-communicating children's pain checklist (NCCPC) has displayed preliminary validity and reliability for measuring pain in children with severe cognitive impairments (Dev Med Child Neurol 42 (2000) 609). This study provides evidence of the psychometric properties of a revised NCCPC (NCCPC-R) with a larger cohort of children. Caregivers of 71 children with severe cognitive impairments (aged 3-18) conducted observations of their children using the NCCPC-R during a time of pain and a time without pain. Fifty-five caregivers completed a second set of observations. The score results on the NCCPC-R were: internally consistent, significantly related to pain intensity ratings provided by caregivers, consistent over time, sensitive to pain, and specific to pain. Analyses of children's individual scores indicated up to 95% of their scores were consistent. Receiver operating characteristic curves suggest a score of 7 or greater on the NCCPC-R as indicative of pain in children with cognitive impairments, with 84% sensitivity and up to 77% specificity. These results provide evidence of NCCPC-R having excellent psychometric properties.

Adolescent↗

Genetics in disorders of language.

As is typical in science, early work in an area is bound to have weaknesses. Therefore, it is not unexpected that the extent to which conclusions can be drawn from the current research on the genetics of DLD is limited. These limitations stem from the use of heterogeneous samples, the use of overly broad phenotypes, survey rather than objective test data, and only a few studies looking beyond simple familiarity. Future research is in progress that attempts to correct for these weaknesses. Still, some practically useful information can be gleaned from the work done thus far. First, we can now hypothesize something about the pathway from gene to DLD phenotype. Much of DLD, like RD, may be a manifestation of early genetic effects on the structural development of the brain (e.g., Plante, Swisher, and Vance, 1991; Plante, 1991; Molfese and Betz, 1988). However, consequences of these genetic effects for language development can still be modified by environmental events (e.g., treatment). Furthermore, genetic effects do not act in isolation and they are not necessarily static. A number of genetic and non-genetic events in the course of development may positively or negatively modify the disorder (e.g., Tomblin, 1989, Tallal et al., 1991; Molfese and Holcomb, 1989). A related point is that there is evidence for genetic heterogeneity in DLD. That different modes of transmission have been put forth by different authors, suggests that a variety of genetic forms of DLD may exist. This idea is further supported by noting that DLD is a common outcome of a number of clinical syndromes having very different genetic bases (e.g., Williams syndrome, Down syndrome, fragile X, etc.; Siegel-Sadewitz and Shprintzen, 1982; Bellugi et al., 1991). This does not rule out the possibility that a majority of nonsyndromic DLD is due to one or a few major genes, however. Finally, there is also evidence for behavioral heterogeneity in DLD. The data suggest that the genes for DLD are variably expressed. For example, in families selected through a DLD proband, a number of different language-related problems have been noted. Furthermore, when a globally defined DLD individual is examined closely, it is common to find a collection of symptoms, sometimes spanning all the major domains of language (Weiss and Lillywhite, 1981). Overall, the data and concepts presented in this article suggest that the clinician should take careful family histories of clients and, when doing so, attempt to ascertain the specific symptoms that family members other than the client exhibit.(ABSTRACT TRUNCATED AT 400 WORDS)

Child↗

Liver transplantation for the treatment of urea cycle disorders.

The principal goal of therapy when liver transplantation is used for the treatment of metabolic disease is to correct the metabolic error. By doing so, liver transplantation eliminates the hepatic and peripheral consequences of the error. Inborn errors involving the urea cycle appear on theoretical grounds to be amenable to treatment using liver transplantation and, indeed, published data demonstrate that this approach to therapy can be successful. The purpose of this study is to examine the outcome of liver transplantation done for the indication of urea cycle defects in a large group of patients. The first goal of the study is to determine with certainty that liver transplantation corrects hyperammonaemia and halts the progress of disease. A second goal is to determine the extent of neurological recovery in children previously injured by hyperammonaemia. The final goal is to understand whether the quality of life is improved and medical expense is reduced by transplantation. The study involved a survey of major transplantation centres. Four centres provided data about 16 patients, 14 of whom were alive 11 months to 6 years after transplantation. The results demonstrate that liver transplantation resulted in correction of hyperammonaemia in all patients. The neurological outcome after transplantation correlated closely with the condition prior to transplantation. This population of patients has had relatively few problems in the long term related to the liver transplant itself. The quality of life seems to be much improved, but further study will be needed to confirm this. Limited data involving two patients show a reduction in the cost of care. We conclude from our experience that liver transplantation can be an effective treatment for children with urea cycle defects.

Amino Acid Metabolism, Inborn Errors↗

Prescription and dosage of analgesic medication in relation to resident behaviors in the nursing home.

OBJECTIVES: To examine correlates of analgesic medication prescription and administration in communicative, cognitively impaired nursing home residents. Residents' behaviors were assessed using computer-assisted real-time observations as potential adjunctive indicators of pain. DESIGN: Cross-sectional study over a 4-week period. SETTING: Five nursing homes in the greater Birmingham, Alabama, area. PARTICIPANTS: Ninety-two residents (mean age +/- standard deviation = 83.86 +/- 8.55) with a mean Mini-Mental State Examination (MMSE) score of 13.81 +/- 6.34. MEASUREMENTS: Data were obtained via chart review, resident assessments, questionnaire completion by certified nursing assistants familiar with residents' care, and direct observation of residents' daily behaviors. RESULTS: Receipt of analgesic medication was related to self-report of pain (F2,89 = 9.89, P =.0001), MMSE (F2,88 = 3.98, P =.022), and time spent inactive (F2,89 = 3.04, P =.053). Residents who received analgesic medication reported greater intensity of pain than other residents. Residents who received analgesics had higher MMSE scores than those who did not receive analgesics. Residents who received analgesics spent less time being inactive than those not prescribed analgesics. Receipt of higher dosage of opioid analgesic medication was associated with more time spent with others in verbal interaction (r =.22, P =.03). CONCLUSION: This study refines the methodology of measuring analgesic medication dosage and its effect on resident behavior. Analgesic prescription and administration patterns are related to time residents spend being inactive. Results suggest that opioid analgesics may hold particular promise in alleviating pain, as indicated by resident behaviors.

Aged↗

Building a relationship: communications and relationships between staff and stroke patients on a rehabilitation ward.

Communications among staff and patients on a stroke rehabilitation ward form the focus of this article, which reports on some aspects of a larger study using a grounded theory approach. Tape-recorded interviews were transcribed and analysed concurrently according to recommendations for the approach. A main theme entitled building a relationship was identified, and this process was found to occur in a context varying from participative at one end of a continuum to hierarchical at the other. Building a relationship was found to be influenced by role, personal qualities and organizational context. Appropriate relationships between role-holders were subject to negotiation, leading to a resulting congruence or incongruence between participants' expectations of each other and their roles. Personal qualities were brought into play in the process, with patients' views of staff and staff views of patients both being influential. Some of these views seemed to parallel what has been described in earlier literature as 'the sick role' and the labelling of patients as 'good' or 'bad'. Responses to personal qualities led to nurses ascribing meaning to patients' behaviour in terms of adjustment to their stroke, giving time to them to help them to adjust, and withdrawal and handing over to other staff if this strategy failed. Organizational context also had an influence on building a relationship, with time constraints being identified particularly by nurses, and the need to fit in the most essential aspects of care. Place was also important, in that nurses were confined to the ward as a work location, whereas other therapists and doctors worked in other places and sometimes had the facility to take patients off the ward to concentrate on therapy. The findings are discussed against the background of related literature and the conclusion is drawn that the crucial role of nurses in rehabilitation is not recognized and valued, and that shortages of resources-especially suitably qualified and trained nursing staff-are a negative influence on building the relationships which are vital to successful rehabilitation.

Cerebrovascular Disorders↗

A genetic study of autism in Costa Rica: multiple variables affecting IQ scores observed in a preliminary sample of autistic cases.

BACKGROUND: Autism is a heritable developmental disorder of communication and socialization that has not been well studied in Hispanic populations. Therefore, we are collecting and evaluating all possible cases of autism from a population isolate in the Central Valley of Costa Rica (CVCR) for a clinical and genetic study. METHODS: We are assessing all subjects and parents, as appropriate, using the newly translated Spanish versions of the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS) as well as tests of intelligence and adaptive behavior. Detailed obstetric and family medical/psychiatric histories are taken. All cases are tested for Fragile X and will be extensively evaluated for cytogenetic abnormalities. RESULTS: To date we have obtained clinical evaluations on over 76 cases of possible autism referred to our study and report data for the initial 35 complete cases. The mean age of the probands is 6.7 years, and 31 of the 35 cases are male. Twenty-one of the cases have IQs <50 and only 6 cases have IQs > or = 70. Over half of the mothers had complications during pregnancy and/or delivery. No cases have tested positively for Fragile X or PKU. Chromosomal G-banding is not yet complete for all cases. CONCLUSION: Diagnostic data gathered on cases of autism in the CVCR using Spanish versions of the ADI-R and ADOS look similar to that generated by studies of English-speaking cases. However, only 17% of our cases have IQs within the normal range, compared to the figure of 25% seen in most studies. This result reflects an ascertainment bias in that only severe cases of autism come to treatment in the CVCR because there are no government-sponsored support programs or early intervention programs providing an incentive to diagnose autism. The severity of mental retardation seen in most of our cases may also be exaggerated by the lack of early intervention programs and the use of IQ tests without Costa Rican norms. Still, we must formally train healthcare providers and teachers to recognize and refer autistic cases with normal or near normal IQs that are not seen in treatment.

Adult↗