Mary Steichen Calderone,M.D.

Pastoral Psychology -     

A comparison of the diagnostic accuracy of the AD8 and BCAT-SF in identifying dementia and mild cognitive impairment in long-term care residents

We compared the accuracy of the Brief Cognitive Assessment Tool—Short Form (BCAT-SF) and AD8 in identifying mild cognitive impairment (MCI) and dementia among long-term care residents. Psychometric analyses of 357 long-term care residents (n = 228, nursing home; n = 129, assisted living) in Maryland referred for neuropsychological evaluation evidenced robust internal consistency reliability and construct validity for the BCAT-SF. Furthermore, hierarchical logistic regression and receiver operating characteristic curve analyses demonstrated superior predictive validity for the BCAT-SF in identifying MCI and dementia relative to the AD8. In contrast, previously reported psychometric properties or cut scores for the AD8 could not be cross-validated in this long-term care sample. Based on these findings, the BCAT-SF appears to be a more reliable and valid screening instrument than the AD8 for rapidly identifying MCI and dementia in long-term care residents.     

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.     

EFFECTS OF STIMULANT MEDICATION UNDER VARIED MOTIVATIONAL OPERATIONS

We evaluated the evocative effects of four conditions (high‐ and low‐preference activities, low and divided attention) and stimulant medication on the behavior of a 16‐year‐old boy with attention deficit hyperactivity disorder and moderate mental retardation. All behavior (activity engagement, activity changes, inappropriate touching, rude behaviors, and physical aggression) improved with stimulant medication in most conditions, but undesirable behaviors were not reduced to acceptable levels in all conditions. This finding suggests that stimulant medication may be a valuable adjunct to function‐based interventions.     

European developments

The British National Health Service is 50 years old. The provision of many services has changed considerably through this time in ways that reflect shifts in organization and philosophy. The provision of psychotherapy has been particularly sensitive to these changes in ways that have made it more widely available but also shaped its content. As the pace of change continues to accelerate, some implications of the most recent shifts in philosophy for clinical practice are considered.     

Book reviews

Institutions represent both the conscious and unconscious aspects of the interacting members. Psychotherapists need to address their unconscious position in the institution as well as the conscious aspects of their work. This paper describes the possible relevance that psychotherapy may have at the unconscious level. The notion of the ‘social defence system’ is extremely useful in finding one's way in the engulfing emotional attitudes, and for tolerating the often dismaying sense of irrelevance that psychotherapy appears to attract. The social defence system of a prison and a mental hospital are considered in this light and some thought are devoted to the changing state of the National Health Service at present.     

An evaluation of three methods of saying "no" to avoid an escalating response class hierarchy

We evaluated the effects of three different methods of denying access to requested high-preference activities on escalating problem behavior. Functional analysis and response class hierarchy (RCH) assessment results indicated that 4 topographies of problem behaviors displayed by a 13-year-old boy with high-functioning autism constituted an RCH maintained by positive (tangible) reinforcement. Identification of the RCH comprised the baseline phase, during which computer access was denied by saying "no" and providing an explanation for the restriction. Two alternative methods of saying "no" were then evaluated. These methods included (a) denying computer access while providing an opportunity to engage in an alternative preferred activity and (b) denying immediate computer access by arranging a contingency between completion of a low-preference task and subsequent computer access. Results indicated that a hierarchy of problem behavior may be identified in the context of denying access to a preferred activity and that it may be possible to prevent occurrences of escalating problem behavior by either presenting alternative options or arranging contingencies when saying "no" to a child's requests.     

Differential reinforcement of alternative behavior increases resistance to extinction: clinical demonstration, animal modeling, and clinical test of one solution

Basic research with pigeons on behavioral momentum suggests that differential reinforcement of alternative behavior (DRA) can increase the resistance of target behavior to change. This finding suggests that clinical applications of DRA may inadvertently increase the persistence of target behavior even as it decreases its frequency. We conducted three coordinated experiments to test whether DRA has persistence-strengthening effects on clinically significant target behavior and then tested the effectiveness of a possible solution to this problem in both a nonhuman and clinical study. Experiment 1 compared resistance to extinction following baseline rates of reinforcement versus higher DRA rates of reinforcement in a clinical study. Resistance to extinction was substantially greater following DRA. Experiment 2 tested a rat model of a possible solution to this problem. Training an alternative response in a context without reinforcement of the target response circumvented the persistence-strengthening effects of DRA. Experiment 3 translated the rat model into a novel clinical application of DRA. Training an alternative response with DRA in a separate context resulted in lower resistance to extinction than employing DRA in the context correlated with reinforcement of target behavior. The value of coordinated bidirectional translational research is discussed.