Quality and Individualization in Wraparound Team Planning

In children’s mental health, collaborative, team-based individualized service planning is most commonly known as wraparound, and has become one of the primary strategies for improving services and outcomes for children with the highest levels of need. We report on analyses of data gathered at 72 wraparound team meetings from communities around the United States. We describe the composition of the teams and the quality of the planning process they engaged in, and explore the extent to which these factors were associated with team member satisfaction and the individualization of plans. Teams in our study were numerically dominated by professionals. Parents attended a large majority of meetings, participation by youth and family advocates was frequent, participation by other family members infrequent, and participation by other members of the family’s informal or natural support networks rare. Observed teams varied considerably in the quality of their planning process and the degree of individualization of plans. Higher-quality planning was significantly associated with increased individualization of plans and with team member satisfaction with meeting productivity.     

Care of the Self and Patient Participation in Genetic Discourse: A Foucauldian Reading of the Surgeon General's “My Family Health Portrait” Program

Critics of genetic discourse are concerned that deterministic and discriminatory views of genetics are increasingly becoming adopted. These views argue that current genetic discourse becomes a source of power whereby powerful institutions harm people with so-called “bad” genes. This essay argues that current analyses of the power of genetics discourse are grounded in an improper reading that disempowers patients. Deploying Michel Foucault's concept “care of the self,” this essay claims that genetics discourse is better understood as a way that patients take on power through rhetoric rather than a force that has power over patients. Through a close reading of the “My Family Health Portrait” program, this paper argues that patients experience a process of “subjection” wherein they become agents of and objects of genetics discourse both. This alternative mode of analyzing the power of genetics discourse has implications for our collective understanding of the operations of the care of the self and the uses of genetic information that we propose.     

Parent Perception of Elementary School Aged Children’s Sleep Problems

Wide discrepancies exist concerning the reported occurrence of sleep problems for elementary school children. We describe parental perception of sleep problem behavior in elementary school aged children 5–12 years. Approximately 4% of parents reported their children experienced significant global sleep problems serious enough to adversely affect family functioning. Significant specific sleep problems reported by parents occurred for approximately 9–14% of the children in the sample. These ranges were in the low end of the ranges of sleep problems reported in previous literature for this age group.     

School Mobility and Students with Emotional Disturbance

We examined the school mobility of a cross-sectional sample of 70 secondary-age youth with emotional disturbance (ED). Data were collected through an archival review of school records. Students’ school mobility histories were examined in terms of the overall number of schools attended in the elementary school years, as well as the timing of the moves that were made. Findings indicate that sample students experienced high rates of school mobility with 66% having changed schools at least once by the end of 2nd grade and 89% having changed schools at least once by the end of 5th grade. Strategies for minimizing school mobility and the impact of high rates of school mobility are reviewed.     

Differences in Individual Approaches: Communication in the Familial Breast Cancer Consultation and the Effect on Patient Outcomes

This multicenter study aimed to assess (i) whether individual clinical geneticists and genetic counselors vary in their communication skills and (ii) whether this variation in communication impacts on patient outcomes, such as anxiety, depression, genetics knowledge, and satisfaction. One hundred and fifty women from high-risk breast cancer families attending their first genetic counseling consultation completed pre and post-consultation self-report questionnaires. The consultations were audiotaped and transcribed verbatim. Univariate analyses showed highly significant differences between individual clinical geneticists and genetic counselors in: facilitating understanding (p 0.001); facilitating active involvement (p 0.001); facilitating partnership building (p = 0.003); addressing emotional concerns (p 0.001); and discussing prophylactic mastectomy (p = 0.017). Multivariate linear regressions showed that this variation in communication resulted in a greater change in patients depression 4 weeks after the counseling session (p = 0.017). These findings suggest clinical geneticists and genetic counselors have achieved some standardization in communicating information, but showed diversity in their facilitation skills. Communication skills may be a useful area to explore further in this field.     

Evaluating the Impact of Genetic Counseling and Testing with Signal Detection Methods

One measure of the impact of genetic counseling and testing (GCT) is the extent to which it fosters behavioral change that is consistent with mutation status. We describe and illustrate how two different signal detection methods, receiver operating characteristic (ROC) analysis and recursive partitioning, can be used in this context to evaluate the impact of GCT. We analyzed real screening behavior data obtained in the 12 months following GCT for Hereditary Nonpolyposis Colon Cancer (HNPCC) using these two different signal detection approaches. Each approach demonstrated that GCT had an impact on behavioral outcomes, and was effective in fostering behavioral outcomes appropriate to mutation status. The ROC approach demonstrated that GCT was effective because mutation positive and mutation negative individuals could be distinguished on the basis of the number of recommended screening behaviors. The recursive partitioning approach demonstrated that GCT was effective because there were generally high rates of adherence to screening guidelines among subjects. The recursive partitioning technique also identified four subgroups of subjects, each with distinct characteristics, for which tailored interventions could be developed to increase rates of adherence to screening guidelines. Signal detection methods are easily implemented and are useful techniques for evaluating the impact of GCT.     

Classification of Antisocial Behaviors Along Severity and Frequency Parameters

Antisocial behaviors were systematically classified along a hierarchy of seriousness or severity that also accounted for frequency of occurrence and heterogeneity of behaviors. Items from the CD and ODD schedules of the NIMH DISC-IV and from the Elliot Delinquency Scales were listed at specified frequencies. Nine mental health clinicians rated the level of seriousness of each alternative on a scale from 0 (trivial) to 5 (very serious). Reliability of the ratings was assessed. Over two thirds of the items showed excellent agreement among the raters, 8% showed poor agreement and 21% showed fair to moderate agreement. The overall reliability of a single rater’s score was 0.56 and the reliability of the average was 0.84. The classification meets high psychometric standards for reliability and has face validity. The final output provides a classification along a spectrum that takes into account severity, frequency of occurrence during the previous year, and presence of multiple behaviors. It is useful for classification purposes and for longitudinal tracking of antisocial behavior.     

Evaluating Genetic Counseling: Client Expectations,Psychological Adjustment and Satisfaction with Service

Periodic evaluations of genetic counseling services are useful for determining the effectiveness of counseling in meetings its psycho-educational aims, as well as identifying where improvements to the service may be made. This study aimed to evaluate the genetic counseling services provided by Genetic Services of Western Australia (GSWA) to determine the impact of counseling on client expectations, satisfaction with the service, and psychological adjustment, defined as wellbeing and perceived personal control (PPC). A total of 122 clients participated in a self-administered survey conducted pre- and post-counseling. Client expectations of the service as a means of providing information were met, and opportunities for counselors to meet client’s expectations of psychological support were identified. Furthermore, counseling was found to maintain and enhance psychological wellbeing of clients. The role of counseling in facilitating the development of PPC was a key contributor to a high sense of satisfaction in clients.     

Integrated versus segregated accounting and the magnitude effect in temporal discounting

Temporal discounting rates in humans generally decrease as the amount of reward increases, a phenomenon known as themagnitude effect. In the present study, we examined whether temporal discounting and the magnitude effect are related to segregation of choices in terms of gains or losses for waiting for or expediting receipt of a reward. Subjects (N = 24) responded to a series of hypothetical choices about amounts of money available either immediately or after a delay. The immediate and delayed amounts either were presented as integrated amounts in the baseline condition or were segregated as differential gains or losses for choosing delayed or expedited consumption (delay and speedup conditions, respectively). Temporal discounting rates decreased in the segregated conditions, in accord with the standard discounted utility model but contrary to the hypothesis that the subjects were choosing on the basis of reward differentials in the baseline condition. The size of the magnitude effect was comparable in the baseline and the delay conditions but decreased in the speed-up condition. These results challenge explanations of the magnitude effect in terms of an increasing proportional sensitivity property of the utility function (Loewenstein & Prelec, 1992) and the hypothesis that subjects choose on the basis of differentials even when the rewards are presented as integrated amounts.