Clinical utility of dimensional models for personality pathology

Clinical utility is defined as the extent to which the DSM assists clinical decision makers in fulfilling the various clinical functions of a psychiatric classification system. Distinction is made between elements of diagnostic validity that are more or less conditional to utility (i.e., coverage, and consistency with etiology and prognosis) and components of clinical utility in the narrow sense of the term (i.e., user acceptability and accuracy, communication, reliability, subtlety, and clinical decision making). Clinical utility is often considered the driving force behind the respective revisions of the DSM system, yet it has been difficult if not impossible to obtain reasonable levels of clinical utility within categorical classifications of personality disorders. This paper presents evidence that a dimensional diagnostic system will substantially improve clinical utility, especially with respect to coverage, reliability, subtlety, and clinical decision making. In addition, some evidence suggests that the purely dimensional models outperform the so-called hybrid models (i.e., dimensional profiling of categories) with respect to coverage, consistency with etiology, subtlety, and clinical decision making. Several research options that might inform future revisions, including the choice or development of a dimensional classification, are suggested.     

AN ANALYSIS OF SOCIAL SKILLS GENERALIZATION IN TWO NATURAL SETTINGS

The interactional behavior of two groups of elderly mentally retarded residents of a community facility was measured in two generalization situations before, during, and after one group received social skills training. The training group received social skills training within a game format, whereas the contrast group simply played a game with no emphasis on interactional behavior. Results suggested that generalization to natural interactional situations may be delayed following training and that it is more likely in some situations (i.e., with trained peers) than others (i.e., in the presence of untrained peers).     

The Effective Treatment of Juveniles Who Sexually Offend: An Ethical Imperative

This article raises serious concerns regarding the widespread use of unproven interventions with juveniles who sexually offend and suggests innovative methods for addressing these concerns. Dominant interventions (i.e., cognitive-behavioral group treatments with an emphasis on relapse prevention) typically fail to address the multiple determinants of juvenile sexual offending and could result in iatrogenic outcomes. Methodologically sophisticated research studies (i.e., randomized clinical trials) are needed to examine the clinical and cost-effectiveness of cognitive-behavioral group interventions, especially those delivered in residential settings. The moral and ethical mandate for such research is evident when considering the alternative, in which clinicians and society are willing to live in ignorance regarding the etiology and treatment of juvenile sexual offending and to consign offending youths to the potential harm of untested interventions. Encouraging signs of a changing ethical climate include recent federal funding of a randomized clinical trial examining treatment effectiveness with sexually offending youths and the introduction of separate (i.e., developmentally informed) clinical and legal interventions for juvenile versus adult sexual offenders.     

Schizophrenia: refining the phenotype, resolving endophenotypes

The conceptual history of the diagnosis of schizophrenia is reviewed and the current definition of the illness is examined (e.g. DSM-IV). A dimensional alternative to the traditional categorical model of diagnosis is discussed with a specific emphasis on the four dimensions of psychopathology represented by reality distortion (hallucinations, delusions), disorganization (positive formal thought disorder, bizarre behavior), negative symptoms (flattened affect, avolition, alogia, asociality), and premorbid social functioning. Also discussed is the development of structured psychiatric interviews that emerged from the clinical/research context that gave rise to explicit (i.e. operational) diagnostic criteria for schizophrenia. The general methodological approach used to detect valid endophenotypes for schizophrenia liability--i.e. indicators of liability not visible to the unaided naked eye--as well as their potential diagnostic and research utility is presented in overview. The rationale for linking such indicators to schizophrenia liability, which is conceptualized as a latent construct, is also reviewed. Future directions in the development and refinement of the diagnostic approach to schizophrenia and schizophrenia liability are highlighted.     

Sensitivity for Treatment Effects of the Screen for Child Anxiety Related Emotional Disorders

The Screen for Child Anxiety Related Emotional Disorders (SCARED) is a relatively new self-report questionnaire that measures DSM-defined anxiety disorders symptoms in children. The present study examined the treatment sensitivity of the SCARED. Eleven anxiety-disordered children aged 10 to 13 years received cognitive-behavioral treatment, an intervention that is generally known to be effective. Children completed the SCARED on three occasions: (1) 3 months before treatment (i.e., baseline), (2) at pretreatment, and (3) at posttreatment. Before and after treatment, scores on traditional childhood anxiety measures (i.e., State-Trait Anxiety Inventory for Children, Revised Children's Manifest Anxiety Scale, and Fear Survey Schedule for Children) were also obtained. Results showed that children's SCARED scores remained relatively stable from baseline to pretreatment. However, from pre- to post-treatment, significant decreases were evident for the SCARED and for all traditional measures. These results suggest that the SCARED reliably taps treatment effects and, thus, provide further support for its utility as a self-report index of childhood anxiety in clinical and research settings.     

Dimensions of online behavior: toward a user typology.

Online behavior refers to organized (e.g., search) and unorganized (e.g., browse) interactions with both human (e.g., chat) and nonhuman (e.g., database) elements in online environments. The salient features of online behavior are conceptualized as sociability (human connection motives), utility (efficiency orientation), and reciprocity (cognitive stimulation and active involvement). Recently published factor analytic studies support the validity of these three dimensions of online behavior. The proposed Brief Test of Online Behavior (BTOB) contains five rating scale items that determine user position on each dimension of online behavior (i.e., 15 items in total). A typology of online behavior emerges as BTOB scores position users in the three-dimensional space created by the intersection of sociability, utility, and reciprocity. Subsequent research may validate the proposed dimensions of online behavior, establish practical applications of the BTOB, and connect type of user with cognitive, social, and emotional outcomes. For example, users who score high on sociability and reciprocity but low on utility may learn best in interactive and stimulating online environments, which necessarily include self-regulating software.     

In Pursuit of Generalization: An Updated Review

Stokes and Osnes (1989) outlined three principles to facilitate the generalization and maintenance of therapeutic gains. Use of functional contingencies, training diversely, and incorporating functional mediators were recommended. Our review, with most illustrations from studies of youth, updates Stokes and Osnes’s original paper with a focus on evidence-based strategies to increase generalization of therapeutic gains across settings, stimuli, and time. Research since 1989 indicates that training for generalization by increasing the frequency of naturally occurring reinforcers for positive behaviors, and altering maladaptive contingencies that inadvertently reinforce problem behaviors, are associated with favorable treatment outcomes. Training diversely by practicing therapy skills across contexts and in response to varying stimuli is also implicated in clinical outcomes for internalizing, externalizing, and neurodevelopmental disorders. Preliminary research recommends the use of internal (e.g., emotion identification) and external (e.g., coping cards) functional mediators to prompt effective coping in session and at home. Strategies for increasing generalization, including the use of technology, are examined and future research directions are identified.     

A Review of the Effects of Interspersing Procedures on the Stages of Academic Skill Development

Basic and applied research related to the effects of interspersing trials of maintenance (i.e., review) tasks among trials of acquisition tasks on academic skill development is reviewed. In general, empirical research suggests that interspersing procedures are effective in facilitating acquisition, learning rate, and maintenance. However, some inconsistency exists among the data that suggests student learning, in some instances, may be impeded. Research also suggests that interspersing procedures are not conducive to facilitating generalization. The discrepancy between various research findings and the consistent failure of research on interspersing procedures to increase generalization is critically reviewed in relation to a hierarchical learning theory set forth by Haring and Eaton (1978). From this hierarchical learning theory perspective, inconsistent results may be better understood and predicted. Implications for current practice and directions for future research are also discussed.     

Treatment utility of psychological assessment

This article focuses on treatment utility. A definition of treatment utility was provided by S. C. Hayes, R. O. Nelson, and R. B. Jarrett (1987): "We propose to use the phrase the treatment utility of assessment to refer to the degree to which assessment is shown to contribute to beneficial treatment outcome" (p. 963). Various methodologies to examine the treatment utility of assessment are summarized. Treatment utility studies using various assessment procedures (i.e., diagnosis and functional analysis) and various disorders (i.e., unipolar depression, social or interpersonal problems, and phobic disorders) are described. Suggestions are made as to when elaborated assessment and/or treatment utility studies are needed. Limitations on the generalizability of results of any particular treatment utility study are presented. Despite progress, for most assessment procedures and devices, the treatment utility question remains; What is the degree to which assessment is shown to contribute to beneficial treatment outcome?     

Utility of verbal-nonverbal correspondence-training techniques in outpatient pediatric settings

Verbal-nonverbal correspondence training is a behavioral approach recommended in the development of adaptive behaviors and the reduction of problem behaviors. This paper summarizes research findings involving 4 verbal-nonverbal correspondence-training techniques and then illustrates the potential utility of these techniques in general pediatric settings. Particular emphasis is placed on strategies pediatricians could employ to teach patients how to use these techniques effectively to decrease problem behaviors at home (e.g., ADHD, refusing to take the prescribed medication, eating problems) among children seen in outpatient pediatric settings.     

Abandonment and engulfment: A bimodal classification of anxiety in domestic violence perpetrators

Multiple conceptualizations of male perpetrated domestic violence have been proposed over the last half-century. The present paper highlights the generally implicit emphasis on the central role of abandonment that unites much of this literature, and the limitations of such a singular perspective are considered. Drawing on theoretical and empirical work both within and outside of the domestic violence literature, a complementary mode of anxiety concerned with the experience of loss of oneself opposed to loss of another is identified. It is suggested that a bimodal classification of anxiety in domestic violence perpetrators that considers abandonment and engulfment as complementary modes of anxiety might provide incremental clinical utility in framing IPV as functionally proximity seeking or intimacy titrating. Implications for future research and clinical practice are discussed.     

Clinical utility: a prerequisite for the adoption of a dimensional approach in DSM

A potential obstacle to implementing dimensional representations in the Diagnostic and Statistical Manual of Mental Disorders (DSM) is lack of data about clinical utility and user acceptability. Adopting a dimensional approach would likely complicate medical record keeping, create administrative and clinical barriers between mental disorders and medical conditions, require a massive retreating effort, disrupt research efforts (e.g., meta-analyses), and complicate clinicians' efforts to integrate prior clinical research using DSM categories into clinical practice. Efforts to empirically demonstrate the clinical utility of dimensional alternatives should be a prerequisite for their future implementation in order to establish that their advantages outweigh the disadvantages. Approaches to promote user acceptability and the development of an empirical database include dimensionalizing existing DSM categories and including research dimensions in the DSM appendix.     

Renewal during functional communication training

Functional communication training (FCT) is one of the most commonly prescribed interventions for the treatment of severe destructive behavior exhibited by individuals with intellectual disabilities. Although highly effective, FCT has been shown to fail in some cases when treatment is introduced into the child's typical environment. Basic and translational research on renewal provides a model for studying the relapse of destructive behavior following successful response to treatment in clinic settings using FCT. In the present study, we evaluated whether relapse of destructive behavior could be attributed to the discriminative control of the home context, which was historically correlated with reinforcement for destructive behavior. We implemented baseline contingencies in the home setting with caregivers acting as interventionists (i.e., Context A). We then implemented FCT in a treatment clinic with trained therapists (i.e., Context B). Finally, we introduced FCT in the home setting with caregivers implementing the treatment procedures (i.e., return to Context A). For three of four participants we observed the relapse of destructive behavior consistent with operant renewal. We discuss the implications of these findings with respect to strategies designed to promote generalization of FCT across settings during the treatment of severe destructive behavior.     

The Role of Families and Care Givers as Risk and Protective Factors in Preventing Youth Violence

This paper reviews research which discusses the risk and protective functions that families and other caregivers provide in influencing the development of aggressive behavior in youth. Currently, there is an emphasis on providing violence prevention programs in the school environment, typically with little parental or caregiver involvement. By enhancing the role of families and caregivers in youth violence prevention programs, we assert that an unique opportunity exists to both address specific risk factors for violence while enhancing the protective features of the family. Relatedly, the risk literature on youth violence indicates that the most influential risk factors (i.e., the family, community, and peers) have their principle impact on youth aggression outside the school. We suggest a shift in the focus of violence prevention programming that is more inclusive of families as both a risk and protective agent. In support of this position, relevant theory and reviews of exemplary family-involved programs are offered. Challenges to involving youth caregivers are identified and recommendations for overcoming those challenges suggested. Last, recommendations for future research and public policy in the prevention of youth violence are offered.     

The social utility of performance-approach goals in a selective educational environment

According to the recent research, the educational system fulfills both an educational function (i.e., teaching and training students) and a selection function (i.e., determining students’ future position in the social hierarchy), particularly in higher education. It has been argued that in the university system the selection function provides a social utility value to performance-approach goals (i.e., the goal to demonstrate one’s own competences relative to others), which in turn increases the extent to which students endorse these goals. Two experiments investigated the influence of the salience of the selection function on performance-approach goals’ social value and endorsement. The results showed that the salience of the selection function increased both performance-approach goal endorsement (experiment 1 and 2) and performance-approach goals’ social utility (experiment 2). These goals’ social utility contributes to explaining the effect of the salience of the selection function on performance-approach goal endorsement. Limitations of the present experiments and practical implications are discussed.     

Testing Theoretical Explanations of Intention to Seek Care for a Breast Cancer Symptom1

The purpose of this research was to test theoretical explanations of intention to seek care promptly for a breast cancer symptom. Psychosocial variables (affect, expectations, values, and norms), habit, and facilitating conditions (e.g., insurance) regarding care seeking were proposed to influence intention to seek care promptly. Whether psychosocial variables and habit influenced intention directly or in interaction with facilitating conditions remained unclear. Other variables (i.e., clinical and demographic) were proposed to influence intention by mediation through the theoretical variables. Community-dwelling women without history of breast cancer (N= 99) responded to a questionnaire to assess study variables. In a hierarchical set regression, intention was first regressed on psychosocial variables, habit, and full insurance coverage for care, then on terms representing interactions of insurance coverage with psychosocial variables and habit, and lastly on clinical and demographic variables. Findings revealed that (a) anxiety (measure of affect), utility, (the product of expectations and values), and habit were related to intention, (b) having full insurance coverage did not moderate these relationships, and (c) after controlling for theoretical variables, family history of breast cancer was related inversely to intention. Implications for theory, research, and practice are delineated.     

The effects of programming common stimuli for enhancing stimulus generalization of academic behavior

Programming common stimuli is a strategy for generalizing behavior across settings (Stokes & Baer, 1977). The present study programmed common stimuli (i.e., goal statement and use of a pictorial icon) to generalize the effects of a reinforcement-based intervention for students identified as either developmentally delayed or emotionally disturbed. Results supported the effectiveness of the strategy in producing generalized responding from training to the generalization setting. The importance of methodological rigor in future research exploring generalization and the need to compare generalization strategies are discussed.     

Toward a technology of generalization: The identification of natural contingencies of reinforcement

Applied behavior analysts have directed a growing effort towards the development of a technology for behavioral generalization and maintenance over the past decade. Among the list of potential generalization promoters thought to exist is the natural contingency of social reinforcement (i.e., a behavioral trap) for new behavior in its untrained form or setting, or over time. Although past researchers have noted a need to program for the generalization and maintenance of behavior change, the current understanding of behavioral traps precludes the use of these contingencies to support behavioral changes when interventions are not in operation. This article describes five forms of evidence useful for the identification and analysis of natural contingencies of reinforcement. Examples from the applied research literature are provided to illustrate the kinds of studies that would greatly enhance our knowledge of behavioral traps and improve our ability to understand and program the generalization of trained behaviors across diverse forms and settings, and over time.     

ECONOMIC CONSIDERATIONS IN ESTIMATING THE UTILITY OF HUMAN RESOURCE PRODUCTIVITY IMPROVEMENT PROGRAMS

Three economic concepts (variable costs, taxes, and discounting) are applied and incorporated into the previous utility formulas proposed by Brogden (1946, 1949), Cronbach and Gleser (1965), and Schmidt, et al. (1979, 1982). The resulting utility model indicates that the previous formulas are deficient and can produce upwardly biased utility estimates. Empirical examples based on published research (e.g., Schmidt, et al., 1982) are presented indicating the substantial magnitude of the bias given realistic levels of variable costs, taxes, and discount rates. The present utility model is used to adjust for such bias and is shown to provide a more complete and precise utility definition. Implications for future research are discussed.