Patient autonomy and the challenge of clinical uncertainty

Bioethicists have articulated an ideal of shared decision making between physician and patient, but in doing so the role of clinical uncertainty has not been adequately confronted. In the face of uncertainty about the patient's prognosis and the best course of treatment, many physicians revert to a model of nondisclosure and nondiscussion, thus closing off opportunities for shared decision making. Empirical studies suggest that physicians find it more difficult to adhere to norms of disclosure in situations where there is substantial uncertainty. They may be concerned that acknowledging their own uncertainty will undermine patient trust and create additional confusion and anxiety for the patient. We argue, in contrast, that effective disclosure will protect patient trust in the long run and that patients can manage information about uncertainty. In situations where there is substantial uncertainty, extra vigilance is required to ensure that patients are given the tools and information they need to participate in cooperative decision making about their care.     

The role of attachment in responses to victims of life crises

Attachment effects on affect, cognitions, and behavior during an interaction with a confederate who purportedly had cancer and whose attachment orientation had been manipulated in a prior context were examined among 241 participants. Results supported theoretically derived predictions: Participant anxious attachment predicted anxiety, participant avoidant attachment predicted supportiveness, and participant avoidant attachment interacted with confederate avoidant attachment to predict rejection. Results suggest (a) the importance of attachment in predicting interpersonal responses in a nonromantic stressful context, (b) that anxious attachment is an important predictor of anxiety in a situation with implicit support demands, (c) that avoidant attachment is a potentially important predictor of the likelihood of supportive responses to victims, and (d) that attachment orientation can be successfully manipulated in experimental studies of attachment.     

Expanding Mental Health Services to Older High-Utilizing HMO Patients: A Pilot Study

Background: Expanded mental health benefits were offered to older HMO patients who were high medical utilizers. Outcomes of interest were use of services, subjective well-being, and psychopathology. Methods: Sixty-nine (25 male, 44 female) patients age 55 or above seeking frequent outpatient medical care completed the SF-36 health survey and the revised Symptom Check List (SCL-90-R). Patients were assigned to usual care, health education, or expanded mental health benefit conditions. Results: Patients showed high initial levels of psychopathology and distress. Over the 6 months of the study, patients in the expanded benefits group made a mean of 11.5 visits to mental health professionals versus a mean of 3.4 visits by usual care patients. Patients in the expanded benefits group showed significant improvement in SF-36 General Health and Mental Health well-being scores. Patients in the health education group showed no improvement. Patients in the usual care group showed improvements in Vitality scores. Psychopathology summary scores showed improvement for both usual care and enhanced benefit groups. Conclusions: Mental health treatment may improve well-being and reduce psychopathology in older high-utilizing patients. Creativity will be needed in expanding access to mental health services for this population.     

Grounded Theory in Genetic Counseling Research

The practice of genetic counseling is in need of evidence-based theoretical frameworks. Although strategies used in genetic counseling are increasingly evidence-based, the field of genetic counseling does not have a generally accepted theoretical basis for development of therapeutic interventions. We know very little about (1) what actually happens in genetic counseling and (2) the impact it has on clients and their families. A number of researchers have used a variety of approaches in an attempt to introduce some theoretical basis for genetic counseling research and practice. Other workers have used experience in their clinical practice to write theoretically about the kinds of processes that might be going on in and around genetic counseling. However, there are few studies to date, which have attempted to build theory modeling the psychosocial processes that take place in and around the genetic counseling clinic using empirical data. This paper describes a methodology (grounded theory) that is designed specifically to build theory about psychosocial processes from a strong evidence base, and explains how it can contribute to the development of practice in genetic counseling.     

Stereotype Threat,Social Class,Gender, and Academic Under-Achievement: When Our Reputation Catches Up to Us and Takes Over

According to Steele (1997), negative stereotypes about intellectual abilities can act as a threat that disrupts the performance of students targeted by bad reputations. Previous research on stereotype threat has showed that on a stereotype-relevant test, stigmatized group members (e.g., African Americans) performed worse than others on an intellectual verbal task. However, when the instructions accompanying the test did not create stereotype threat, stigmatized group members' performance was equal to that of other participants. In this paper, we present studies documenting the effect of stereotype threat and discuss ways to counter it. Two strategies derived from Self-Categorization Theory (Turner & Oakes, 1989) and Self-Affirmation Theory (Steele, 1988) are presented, tested, and discussed. This revised version was published online in August 2006 with corrections to the Cover Date.     

Cognitive imitation in typically-developing 3- and 4-year olds and individuals with autism

Individuals diagnosed with autism suffer from numerous social, affective and linguistic impairments. It has also been suggested that they have a global imitation deficit. That hypothesis, however, is compromised by the fact that individuals with autism suffer from various motor impairments. Here we describe an experiment on cognitive imitation, a type of imitation that doesn’t require motor learning. Nine male autistic subjects and 20 typically-developing 3- and 4-year olds were trained to respond, in a prescribed order, to different lists of photographs that were displayed simultaneously on a touch-sensitive monitor. Because the position of the photographs varied randomly from trial to trial, sequences could not be learned by motor imitation. In three different imitation treatments, including a ghost control, autistic subjects learned new sequences more rapidly after observing a model execute those sequences than when they had to learn new sequences entirely by trial and error. Moreover, the performance of autistic subjects did not significantly differ from the performance of typically-developing controls. The result of this and other studies suggests that individuals with autism suffer from a specific novel motor imitation deficit.     

Home Versus School Environments and their Influences on the Affective and Behavioral States of African American,Hispanic, and Caucasian Juvenile Offenders

We examined and compared the influence of home and school environments to the affective (anxiety and depression) and behavioral (impulsivity and compliance) states of 626 African American, Caucasian, and Hispanic adjudicated juvenile offenders. African Americans showed the strongest relationship between their home environment and compliance. Caucasian and Hispanic males exhibited increased home and school environment problems associated with affective states. Among females, African American and Caucasian females exhibited the strongest relationships between their home environment and behavioral states, whereas Caucasian and Hispanic males revealed increased school environment problems related to affective states with Hispanic males showing the strongest relationships. In addition, the school environment was more predictive of the affective and behavioral states of the adolescents, particularly females.     

Description of a Behavioral Intervention to Reduce Substance Use and Related Risk and Increase Positive Parenting among Urban Mothers with Alcohol and Other Drug Problems

The abuse of alcohol and other substances by mothers raising adolescent children has serious adverse effects on family functioning and youth outcomes, and on mothers’ own health and adaptation. Mothers who are also HIV-infected face additional challenges. In the present report, we describe a multi-session intervention conducted in individual sessions for mothers with alcohol and other substance use problems who are raising adolescent children. We outline the primary components of the intervention and include case studies and examples of exercises and tools. We found that engagement with the intervention and high rates of attendance were facilitated by tapping into mothers’ desires to improve their relationships with their adolescent children, the use of a harm reduction approach toward substance use, and intensive outreach. We also discuss lessons learned in the course of implementing and evaluating the intervention.     

The Impact of Teasing on Children’s Body Image

Being teased about one’s physical appearance in childhood has been found to have a strong impact on the way in which adolescent and adult women perceive their bodies. Teasing is also strongly related to self-esteem in children. However, little is known about the impact of teasing on the development of body image in childhood. Through a quantitative study of the experience of being teased and body image satisfaction in a group of 431 primary aged children, we examined the prevalence, type and impact of teasing on children’s perceived body image satisfaction. The results of our study indicated that many children, especially those who are over or underweight experience being teased. This experience does have a negative impact on children’s body image. This is especially significant for young girls and boys who are overweight. Underweight young boys also suffer negatively from this experience. It is important for parents and others to understand that what may be perceived as friendly banter with their children may not necessarily be innocuous. Further research exploring the concept and construct of teasing in childhood is warranted.     

Unique pathways to resilience across cultures

An international mixed methods study of resilience of 14 sites in eleven countries identified seven tensions that youth resolve in culturally specific ways. Resolution of these tensions is foundational to experiences of resilience. This paper reports on the qualitative findings from interviews with 89 youth. Results support a culturally embedded understanding of positive youth development that better accounts for young people's resilience in western and non-western countries. Specifically, the seven tensions identified include: access to material resources, relationships, identity, cohesion, power and control, social justice, and cultural adherence. Findings show that no one pattern in the resolution of these tensions predicts resilience better than another. A case study of a Palestinian boy demonstrates the intersection of the seven tensions and the uniqueness of their resolution. The implications of this work for interventions is discussed.