The assessed crisis service needs of clients in community-based programs serving persons with developmental disabilities

Crisis services for persons with developmental disabilities who display challenging behaviors is rapidly emerging as a critical need for individuals placed in the community. Many states continue to close their large state facilities for persons with developmental disabilities. Challenging behaviors impedes successful living in the community. A questionnaire providing information on the types of challenging behavior, the availability and perceived need for on-site and off-site crisis-respite support services, and the optimal method of accessing community-based crisis services, was sent to Minnesota residential facilities in the metropolitan and rural areas. The results revealed commonalities between these respondents as well as the differences. As the national trend of deinstitutionalization continues, the information derived from this study will be useful for the development of crisis services in other states. © 1998 John Wiley & Sons, Ltd.     

Wraparound care in vermont: Program development,implementation, and evaluation of a statewide system of individualized services

Over the past decade, there has been a dramatic shift in the provision of mental health services to children, adolescents, and their families. This shift has been marked by a movement away from restrictive treatment options toward the development of comprehensive community-based systems of care designed to keep the most challenging children in their homes, schools, and communities. Based on a model of intensive case management referred to as Wraparound Care, Vermont's statewide approach emphasizes aggressive outreach, use of the least restrictive treatment options, and care that is flexible, unconditional, and child- and family-centered. We chart the development of Vermont's Wraparound Care Initiative and present residential, educational, and behavioral outcome data for a cohort of 40 youth receiving Wraparound Care over a 12-month period. The results showed that after 12-months, youth who had been previously removed from their homes or were at imminent risk of such removal, were residing in significantly less restrictive community-based living arrangements and exhibiting significantly fewer problem behaviors than at intake. These results are discussed in light of recent national studies and previous studies on similar cohorts of Vermont youth receiving Wraparound Care.     

Aversive procedures: The minnesota experience

Aversive and deprivation procedures for controlling and reducing challenging behaviors have received increasing attention. Many states have adopted guidelines on the use of these procedures treating persons with developmental disabilities. The Minnesota state rule promulgated in October, 1987 requires reviews from both local and state-wide review committees on permitted, but controlled procedures. Data generated from state-wide committees revealed that (a) state operated regional treatment centers (RTCs) employed individual habilitative training programs with controlled procedures more frequently than community-based agencies (b) a higher proportion of RTC submissions were for treatment of self-injury than submissions from community services, and (c) RTCs had a higher usage of mechanical restraints than community facilities with both services settings using manual restraints more frequently than all other controlled procedures combined. Reasons for the above differences in the two service settings were discussed.     

Evaluating the vermont system of care: Outcomes associated with community-based wraparound services

Evaluation of innovative community-based interventions is becoming a high priority for child and adolescent mental health service system research. The present study examined outcomes for a sample of Vermont children (N=27) experiencing emotional and behavioral problems and receiving individualized, wraparound services. One year after initiation of wraparound care, incidence of negative behaviors rated as placing a child at risk of removal from the community had decreased significantly, compliance behavior had increased, and a significant decline in Total Problem Behavior scores on the Child Behavior Checklist was observed. In addition, though 70% of the participants had previously required inpatient or residential treatment, 89% were maintained in the community after one year of services, and the total cost of services was less than that of out-of-state residential care. Although further comparative research is needed, this study suggests that for many of these children, wraparound services may be a more efficient intervention than long-term psychiatric hospitalization or residential treatment.     

Developing comprehensive,individualized community-based services for children and youth with emotional and behavior disorders: Direct service providers' perspectives

Increased attention to the plight of children and youth with emotional or behavioral disorders (EBD) and their families has led to innovations in the manner in which these individuals are served. Two such innovations have been the development of public systems of comprehensive, community-based care and individualized wraparound services. This study was part of one community's attempt to merge these two innovations and provide individualized wraparound services to children and youth with EBD through the auspices of public agencies. Direct service providers were surveyed to gather their input into how such services could best be developed and implemented. The survey focused on existing barriers to providing services and specific service priorities for system development. Methods and results are presented. Implications for the local system and future research needs are discussed.     

Satisfaction,involvement, and unconditional care: The perceptions of children and adolescents receiving wraparound services

Client satisfaction has emerged as an important variable in evaluating outcomes for mental health treatment, yet studies have seldom queried children and adolescents about their perceptions of the services they receive. The present study surveyed 20 youths receiving community-based, wraparound services about their satisfaction, sense of involvement, and feelings of unconditional care. Unconditional care, in this case, referred to the youth's sense that his or her caretakers would remain stable regardless of what happened. Each of these variables was in turn related to behavioral adjustment. It was found that both youths' sense of involvement and their perceptions that their care was unconditional were strongly associated with satisfaction with services. However, neither satisfaction nor involvement were correlated with the severity of subjects' acting-out behaviors. Subjects' perception that care was unconditional was strongly, negatively correlated with the severity of acting-out behaviors. Thus, while the relationship between satisfaction and behavior remains unclear, it appears that youths' perceptions of the stability of their services plays a role in their acting out. It was concluded that youths' feelings about their services can provide meaningful information for researchers and service providers.     

Establishing psychological services in a community-based,health care setting: A 3-year case study

Health care practitioners are being challenged to reorganize service delivery and psychology providers are emerging as important participants in shaping the development of primary health care practices. The article outlines the 3-year process of a community/academic/health care center partnership to develop a new model for providing interdisciplinary health care services. The authors describe the process of integrating psychological services into an interdisciplinary, primary care community-based health care center, outline specific planning strategies, and identify the roadblocks and barriers encountered.     

Using a Mindfulness-Based Procedure in the Community: Translating Research to Practice

Maladaptive behaviors, such as aggressive and disruptive behaviors, are a significant risk factor for maintaining community placement by individuals with intellectual disabilities. When experienced researchers provide training to individuals with intellectual disabilities on a mindfulness-based strategy, Meditation on the Soles of the Feet, the individuals are able to effectively self-manage their maladaptive behaviors. We investigated whether similar effectiveness would be found if community-based therapists provided the training to similar individuals living in the community. Three adults with mild intellectual disabilities and mental illness living in the community were taught by a community-based therapist to use this strategy to control maladaptive behaviors that included verbal aggression, disruptive behavior and physical aggression. They were taught to shift the focus of their attention from the negative emotions that triggered their maladaptive behavior to a neutral stimulus, the soles of their feet. All three individuals were able to reduce their maladaptive behaviors to near-zero levels and maintain their community placement that they had been at risk for losing, due to their maladaptive behavior. Subjective measures of various psychological symptoms showed a reduction in two of the individuals. Our study suggests that the demonstrated effectiveness of Meditation on the Soles of the Feet can be achieved by a community-based therapist.     

Mutuality in medical services

While available to a multitude, routine health precautions and basic, nonspecialized medical services are lacking in many societies. This may in part be the outcome of attitudinal distortions, not only at the national and global levels, but fundamentally within the patient-physician encounter. Demands for a disturbance-free subsistence clash with values of power and control within health-care sub-systems resulting in an overall neglect of primary needs and a distribution of medical services that benefits select groups. True needs are misrepresented and an intensification of particular services does not fulfill one's duties toward those who realize little or no services at all. The entire institutional system of medicine requires a rebalancing of rights, intentions and outcomes, beginning with the correlative experiences of patient and physician.     

Multisystemic therapy treatment of substance abusing or dependent adolescent offenders: Costs of reducing incarceration,inpatient, and residential placement

The development of more effective and less costly family- and community-based services to serve as alternatives to out-of-home placements of children is an important priority in the reform of mental health services for children and adolescents. Within the context of a randomized trial with 118 substance abusing or dependent juvenile offenders, we examined the incremental costs of multisystemic therapy (MST) and related these costs to observed reductions in days of incarceration, hospitalization, and residential treatment at approximately 1 year postreferral. Results showed that the incremental costs of MST were nearly offset by the savings incurred as a result of reductions in days of out-of-home placement during the year. The need to validate effective treatments for youth with serious clinical problems and to link the costs of treatment     

A systematic review of cultural adaptations in the global application of ABA-based telehealth services

With telehealth gaining acceptance as a service delivery method, behavior analysts are now providing services to individuals worldwide. This review highlights the cultural adaptations used in ABA-based telehealth treatments for individuals with ASD outside of the United States. Nine studies met our inclusion criteria and the data were synthesized narratively. All studies reported some type of cultural adaptation, with most studies reporting changes made to the service delivery method. This included using translated materials; training in the language of the client; and matching the trainer in birthplace, ethnicity, or gender with the participants. The adaptations described in published research can serve as a resource for behavior analysts who have interest in global telehealth services. However, given the emerging nature of this area of research, it is challenging to know which adaptations are necessary to achieve optimal outcomes. The review concludes with ideas for research development in this area.     

FOCUSING ON PARTICIPANTS

This article presents a model developed and assessed by a women's health research team to enhance sensitivity and increase readability of a survey to be used with community-based women. The survey consisted of quantitative measures of AIDS-related attitudes and behaviors, developed and used with traditional-aged college populations, and included questions of a highly personal nature. In Study 1, 30 women with English reading levels of third grade and above from two targeted community populations completed a survey in two waves of focus groups and gave feedback about readability, length, format, content, emotional responses, truthfulness in responding, and opinions about the research. Problem areas and changes that made the survey more readable, understandable, emotionally sensitive, and effective are reviewed. In Study 2, pre- and postmodification versions of nine scales are compared in 430 traditional-aged college women (pre) and 793 community-based women (post), the latter broken into subsamples for more refined comparisons. Results of five psychometric analyses demonstrate that psychometric integrity does not have to be hurt by such changes. In addition, this process illustrates how researchers can gain a better understanding of participants and their reactions to the research process through qualitative research methods.     

Building a research base for community services for children and families: What we know and what we need to learn

We examine the knowledge base for community-based mental health services for youth and their families. A brief historical perspective on the development of community services is presented, and the fundamental components of a comprehensive child mental health service system are described. Outcome studies for service components as well as the service system as a whole are summarized. Research related to the context of treatment, i.e., service setting, cost, is presented. The authors conclude that a research base for child and family services is emerging, but there is still a paucity of well designed studies that address the complexities of a community-based system as well as the critical outcome questions that need to be addressed. Finally, promising service system developments are described and recommendations for future research are presented.     

A taxonomy for financial services selling

The financial services industry accounts for almost half of the country’s nonfarm, commercial profit, making the industry a major driver of the economy. Prior to this study, limited information was available to evaluate financial services sales activities, and a taxonomy of sales activities for individuals in the financial services industry had not previously been conducted. Prior empirically developed sales taxonomies did not include service firms and specifically financial services, while focusing on manufacturing and other product sales. Given that taxonomies are a critical step in scientific inquiry, this is a major limitation in the literature hindering the development of a better understanding of this important industry. Using an established methodology and a seminal sales taxonomy, a financial services sales taxonomy was conducted. Results reflect that financial services sales positions differ from those in other industries. Six sets of sales activities (factors) along with six job positions (clusters) were identified.     

Changes in intertemporal choices in deviant behaviors

Delay discounting is the process of devaluing results that happen in the future. We present a comprehensive literature review of changes on intertemporal choices in deviant behaviors, namely in (a) substance-related and addictive disorders, (b) disruptive, impulse-control, and conduct disorders, and (c) eating disorders. We also present studies focused on differences in demographic characteristics of the populations by gender, age, and education/social class. Delay discounting is presented as a process of studying intertemporal choices, resulting from decades of empirical research. Studies indicate that this process may provide explanation as to why individuals will sometimes choose a smaller reward, available sooner, instead of a larger reward available later. When studying populations with the above-mentioned problems, they tend to exhibit more pronounced discounting functions than control groups. The association between discounting and gender is not clear. The relationship between delay discounting and age is relatively clear, where older individuals discount less markedly than younger individuals. Studies suggest that shallower discounting gradients are associated with higher levels of intelligence and academic success. We emphasize the need for more empirical research on delay discounting, especially in regard to deviant behavior that may be associated with impulse-control disorders.     

Identifying and understanding gaps in services for adults experiencing homelessness

Gaps between service needs and availability often prevent individuals with a history of homelessness from accessing services and reestablishing permanent housing. This paper examines self‐identified service utilization and service needs based on data collected from an urban sample (N = 577) of adults experiencing homelessness. This study found that individuals differ in their use and continued need of services depending on the reasons they identified as contributing to their homelessness. The majority reported that they learned of services through word of mouth, had difficulty accessing services due to limited transportation options, and were most likely to use services that were in convenient locations that fulfilled their needs and where they were treated with respect. These findings have implications for developing coordinated intakes and the development and dissemination of services aimed at assisting individuals experiencing homelessness.     

Occupational stress and burnout amongst staff working with people with an intellectual disability

The Occupational Stress Inventory (Osipow & Spokane, 1987) and the Maslach Burnout Inventory (Maslach, 1982) were used to assess the levels of occupational stress and burnout amongst staff providing services to people with an intellectual disability both in an institutional and community settings. Data were analyzed to determine the effects of direct client contact, staff mental health, and working environment (institution vs. community). While levels of burnout and occupational stress were not high overall, staff working in an institutional setting scores more highly.     

Court populations in need of services: defining the court's role

Court populations frequently include individuals in need of educational, employment, health, housing, mental health, social, and other types of services that are not commonly provided by the judicial system. Courts vary in the ways they address the service needs of these individuals based on a variety of factors specific to their respective jurisdiction. Following a discussion of some of these approaches, the article offers a framework, based on Bronfenbrenner's human development paradigm and its focus on environmental contexts, to help courts more systematically and comprehensively define their role in service issues within the legal and service parameters of their own jurisdiction. © 1998 John Wiley & Sons, Ltd.     

CBCL Behavior Problems of Post-Institutionalized International Adoptees

With the increase in international adoptions during the last decade, many researchers have investigated the developmental outcomes of these adoptees, including their extreme behaviors. Collectively, these results have not always appeared consistent across studies, perhaps because studies have used children reared in institutions or not, the institutional environments vary in severity, children spend different lengths of time in the institution and are assessed at different ages, and studies use different outcome measures. In an attempt to discern more order in the literature, this review focuses on 18 studies, each of which used the Child Behavior Checklist, and their outcomes are viewed with respect to these parameters. Results suggest that the major factor contributing to extreme behaviors is age at adoption, with those adopted after 6/18 months having more behavior problems, especially Internalizing, Externalizing, and Attention problems. Generally, samples of post-institutional children have more problems than samples of mixed or non-institutional internationally adopted children, and some problems are more likely to be manifest in adolescence, suggesting the effects of deficient early experiences are not simply the persistence of learned behavior but more general dispositions that become more noticeable or severe during adolescence. Findings are discussed in terms of early deficient social–emotional caregiver–child interactions that characterize most institutional environments as a possible major cause of later difficulties in post-institutionalized children.