BEHAVIORAL GERONTOLOGY: APPLICATION OF BEHAVIORAL METHODS TO THE PROBLEMS OF OLDER ADULTS

Elderly persons are under-represented in research and clinical applied behavior analysis, in spite of data suggesting that behavior problems are quite prevalent in both community dwelling and institutionalized elderly. Preliminary investigations suggest that behavioral procedures can be used effectively in treating various geriatric behavior problems. We discuss a number of areas within behavioral gerontology that would profit from additional research, including basic field study, self-management, community caregiver training, institutional staff training and management, and geriatric behavioral pharmacology. Special considerations for adapting behavioral procedures are discussed, and suggestions for expanding the role of behavior analysis in geriatric care are offered.     

Psychology Internships in the Treatment of Severe Mental Illness: Implications for Training in Academic Medical Centers

Despite an increasing focus over the past 2 decades by federal and state governments on the care of persons with severe mental illness, psychologists remain underrepresented among behavioral health professionals working with this population. Within the discipline there is growing concern about the need to adequately train, recruit, and retain psychologists in this specialty. This is a particular concern in academic medical settings where the overall severity of illness among those receiving psychiatric services continues to increase. The purpose of this qualitative research study was to intensively examine the experience of predoctoral interns engaged in treating individuals with severe mental illness in an academic medical center in order to identify the professional developmental experiences and training needs of those learning to care for this population. This analysis, conducted with semistructured interviews at four points during the internship year, yielded a series of recommendations for improving internship training and recruiting psychologists to this specialty.     

Behavioral Health Consultation and Primary Care: Lessons Learned

This article provides an overview of 20 years of professional experiences with developing and implementing a model for integrating behavioral health services into primary care. The Primary Care Behavioral Health (PCBH) model is designed to provide immediate access to behavioral care for a large number of primary care patients by positioning a behavioral health consultant in the exam room area to function as a core member of the primary care team. In an initial era of discovery, the authors were directly involved in developing and testing a variety of new approaches to providing behavioral health services in general medicine. In a second era focused on feasibility, the authors worked with Kaiser Permanente, the United States Air Force and Navy, the Veteran’s Administration, and the Bureau of Primary Care to system test this innovative model of integrated care. Now in an era devoted to dissemination, the authors review the various roles formal research, system level quality improvement initiatives and stakeholder analysis play in promoting integrated care. The authors also describe current efforts to (1) create a tool that helps systems develop integration targets and (2) use the PCBH model as a platform for teaching medical residents and behavioral health providers to work together in a redesigned primary care team model.     

Profiles in Problem Solving: Psychological Well-Being and Distress Among Persons with Diabetes Mellitus

Although social problem-solving abilities have been consistently associated with indicators of behavioral health, this work has been largely confined to tests of specific theoretical issues. Research has yet to demonstrate how the separate elements of the social problem-solving model relate to different patterns of adjustment, particularly among persons who live with chronic disease. We studied the occurrence of different profiles of social problem-solving abilities observed among persons living with diabetes mellitus. We then examined differences between clusters on measures of life satisfaction and depression. Results indicate that distinct profiles in problem-solving abilities do occur and these groupings can be distinguished by their different patterns of adjustment. Implications for theoretical models of problem solving and clinical assessment and interventions for persons with diabetes are discussed.     

Health-related Internet use, coping, social support, and health indicators in people living with HIV/AIDS: preliminary results from a community survey.

Widespread Internet use has revolutionized health information and patient education for persons with chronic illnesses. The authors surveyed 147 HIV-positive persons to examine factors associated with Internet use and associations between Internet use and health. Information, motivation, and behavioral skills associated with using the Internet were related to Internet use. The authors found that health-related Internet use was associated with HIV disease knowledge, active coping, information seeking coping, and social support among persons who were using the Internet. These preliminary findings suggest an association between using the Internet for health-related information and health benefits among people living with HIV/AIDS, supporting the development of interventions to close the digital divide in HIV/AIDS care.     

Interventions with care givers of dementia patients: comparison of two approaches

We compared the effect of two approaches, family counseling and support groups, for relieving the stress and burden experienced by care givers of dementia patients. Both treatments are designed to implement features of a stress-management model that have been identified in prior research with this population: providing information about the patient's disease and its effects on behavior, teaching behavioral problem solving for managing difficult behavior, and identifying potential support for care givers. Subjects were primary care givers of dementia patients living in the community; they included husbands, wives, daughters, and other relatives. Although subjects in the treatment groups made significant gains over time, they did not differ from wait-list subjects who showed similar improvements. One-year follow-up interviews indicated that gains made during the treatment period were maintained.     

Pro-active positioning of a social robot intervening upon behavioral disturbances of persons with dementia in a smart nursing home

Behavioral disturbances of persons with dementia residing in a nursing home impose a significant burden on other residents and on the care staff. A social robot can provide an adequate technological support tool for the caregivers by approaching a resident that exhibits a behavioral disturbance. In this paper, we focus on how to position the robot in the nursing home, taking into account the profile and location of the residents. We minimize the time between the detection of a behavioral disturbance and the robot having arrived near the resident and starting an interaction scenario. Our algorithm is evaluated using realistic data that was collected during 3 months in two Belgian nursing homes.     

A Social Ecological Approach to Investigating Relationships Between Housing and Adaptive Functioning for Persons with Serious Mental Illness

This paper seeks to advance mental health—housing research regarding which factors of housing and neighborhood environments are critical for adaptive functioning, health, and recovery for persons with serious mental illness (SMI). Housing and neighborhood environments are particularly important for persons with SMI because of the prevalence of poor housing conditions among this population. Most mental health—housing research has been limited by a focus on problems in environments and functioning. The paper seeks to expand the mental health—housing research agenda to consider protective factors that promote community integration and adaptive functioning. We provide an account of how social ecology theory transformed a research program, from examining individual risk factors to investigating the functioning of persons in the contexts of their housing and neighborhood experiences. The resulting housing environment framework—physical aspects of housing and neighborhoods, social environment of neighborhoods, and interpersonal relationships tied to housing—allows for identification of opportunities for health promotion and facilitation of participation in community-based settings. This program of research draws upon several methods to understand the social experience of persons with SMI living in community settings—survey research, qualitative interviews, Geographic Information Systems, participatory research, and visual ethnography. In this paper, we present how social ecology theory was instrumental in the development of new housing environment measures, the selection of appropriate research methods, and framing research questions that are building a new empirical base of knowledge about promoting adaptive functioning, health, and recovery for persons with SMI living in community settings.     

Simulation-based research to improve infant health outcomes: Using the infant simulator to prevent infant shaking

Simulation is a technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions. We will first provide an introduction to simulation in healthcare and describe the two types of simulation-based research (SBR) in the pediatric population. We will then provide an overview of the use of SBR to improve health outcomes for infants in health care settings and to improve parent-child interactions using the infant simulator. Finally, we will discuss previous and future research using simulation to reduce morbidity and mortality from abusive head trauma, the most common cause of traumatic death in infancy.     

Overcoming Barriers to HIV Treatment Adherence: A Brief Cognitive Behavioral Intervention for HIV-Positive Adults on Antiretroviral Treatment

Maximizing HIV treatment adherence is critical in efforts to optimize health outcomes and to prevent further HIV transmission. The Balance Project intervention uses cognitive behavioral approaches to improve antiretroviral medication adherence through promoting adaptive coping with medication side effect and distress related to HIV. This 5-session intervention has been documented to prevent nonadherence among persons living with HIV who experience high levels of distress associated with their antiretroviral medication side effects. We describe the theoretical underpinnings of the intervention, provide details of the training and session protocols with a case example, and discuss implications for future applications of the intervention in both research and clinical settings.     

Externalizing behavior challenges within primary care settings

Primary care providers encounter a substantial number of behavioral health concerns leading to the increasing provision of psychological interventions within medical settings. Externalizing disorders present a particular challenge to physicians and stand to benefit a great deal from early intervention. Providing behavioral health services in primary care can reduce barriers to treatment, stigma associated with mental health, and cost of service provision. Given these advantages, scholars have examined the provision of behavioral health interventions within primary care settings. This review provides a critical overview of the extant evidence base and offers suggestions for future efforts in this area.     

Social skills training: The moderating influence of culture in the treatment of Latinos with schizophrenia

Providing effective psychiatric rehabilitation to ethnic minority patients with serious persistent mental illness (SPMI) requires an understanding of the role of cultural values and ethnicity-relevant factors on the course and outcome of severe mental disorders. In this paper, the author identifies some of the cultural factors that are relevant for Latinos with SPMI, and describes how these factors were incorporated into existing rehabilitation modalities. The results of a pilot study designed to test the efficacy of culturally-modified social skills training are presented. The results suggest that the cultural modifications improved Latino patients' ability to learn the material and enhanced their use of these skills in their natural environments. Future research will be aimed at identifying and incorporating these salutary cultural forces into the rehabilitation process of the severely mentally ill.     

The Persistence-Strengthening Effects of DRA: An Illustration of Bidirectional Translational Research

We summarize a series of bidirectional research studies that demonstrate the persistence-strengthening effects of differential reinforcement of alternative behavior on problem behavior. We model a possible solution to this problem with rats followed by replication with a human clinical population. The importance of coordinated basic and applied research to stimulate new behavioral technologies is emphasized.     

TEACHING PERSONS WITH PROFOUND MULTIPLE HANDICAPS: A REVIEW OF THE EFFECTS OF BEHAVIORAL RESEARCH

The behavioral research on teaching individuals who have profound multiple handicaps is reviewed. The primary focus is on determining the degree to which behavioral research has demonstrated the teaching of meaningful skills to this population. Results of the review indicate that investigations have demonstrated, albeit inconsistently, that behavior change has resulted from contingency management interventions with persons who have profound multiple handicaps. However, there is little evidence that such interventions have resulted in meaningful behavior change according to currently accepted criteria for beneficially affecting the quality of life of persons with serious handicaps. Potential explanations for the lack of such evidence are offered, including the relative lack of research attention given to this issue, the possible ineffectiveness of the components of the technology applied, and possible ineffective application of the potentially effective technology. Suggestions for future research are discussed in terms of developing more effective educational and habilitative services for persons with profound multiple handicaps. In particular, we suggest research on a wider variety of behavioral teaching procedures, providing more comprehensive evaluations of the applications of procedures and developing treatment programs that do not focus solely on traditional skill acquisition.     

Domestic Violence Screening in Medical and Mental Health Care Settings

ABSTRACT

Health care providers and patients agree that domestic violence presents a serious health issue that falls within the purview of medical care. The patient-physician encounter has the potential to assist domestic violence victims in considering their options of living without violence and playing a critical role in preventing future violence. Despite this possibility, many persons evaluated in the health care system do not experience the benefits of such interactions. This article reviews current research that evaluates physician, patient, and systems barriers to providing care to patients experiencing domestic violence as well as gaps in the current research and suggestions for how these barriers might be overcome. Educational initiatives, implementation of protocols, and increasing environmental cues that prompt patients and physicians to discuss domestic violence may all increase the likelihood of screening and the success of interventions.     

Integration: Opportunities and Challenges for Family Therapists in Primary Care

Integration of behavioral and physical health is becoming critical for the overburdened primary care system. Policy changes are needed to accommodate integration nationally. Locally, medical and behavioral health providers are working together to create models that better fit their patients?? comprehensive needs while respecting the clinical, operational, and financial constraints of the current system. Family therapists trained to work in medical settings have an opportunity to emerge as clinical, research, and administrative leaders in this context. However, a paradigm shift is crucial to adapting their systemic orientation to interactions between individual patients, providers, staff, and healthcare and support systems. This article provides family therapists with: (1) an overview of the basic structure and barriers of integration, (2) suggestions on how to deliver quality care despite barriers at the local level, and (3) examples of key advocacy efforts representing possible entryways on a larger scale.     

IMPROVING RESIDENTIAL TREATMENT SERVICES: IMPLEMENTATION AND NORM-REFERENCED EVALUATION OF A COMPREHENSIVE MANAGEMENT SYSTEM

Ensuring effective service delivery by direct-care personnel in institutional living units for persons with developmental disabilities historically has been a difficult process, despite considerable attention from researchers, service providers, and governmental regulatory agencies. In this investigation, we conducted a normative evaluation of the extent and quality of treatment services currently provided in residential living units (Experiment 1) and evaluated a comprehensive management system designed to improve such services (Experiment 2). Results of the first experiment, encompassing 22 living units in three states, indicated that on the average two thirds of observed resident behavior did not involve any therapeutic activity. The results also provided social validity for the criteria used to evaluate the quality of treatment provision based on opinions of mental retardation professionals. Results of the second experiment indicated that a behavioral management program implemented during 23 separate time periods across five living units was accompanied by consistent and durable decreases in resident nontherapeutic activity as well as increases in specifically designated habilitative activity. The results provide support for the successful incorporation of behavioral management technology into human service settings on a large-scale, long-term basis.     

Economic Antecedents of Foster Care

Individual and ecological research suggests that rising unemployment may affect the incidence of violence through two countervailing mechanisms suggested by frustration–aggression theory. The first, or provocation effect, assumes increased violence among persons who feel anger because they believe their job loss was arbitrary. The second, or inhibition effect, posits less violence among employed persons who attempt to reduce their chances of job loss by curtailing behavior objectionable to employers. The literature also reports that these mechanisms affect victimization measured as foster care sought by the state for abused children. The foster care finding, although consistent with theory and important for basic as well as applied reasons, arises from methods that cannot rule out several rival hypotheses. We revisit this research and apply improved methods to test the reported association in Los Angeles and San Francisco counties. We find that, as implied by the provocation and inhibition mechanisms, differences in monthly prevalence of foster care placements increase with modest increases in unemployment but decline when unemployment becomes much higher than usual levels.