CONTINGENCY MANAGEMENT INTERVENTIONS: EFFECTS ON TREATMENT OUTCOME DURING METHADONE DETOXIFICATION

We examined the effectiveness of a contingency management program in preventing relapse to illicit opiate use and increasing treatment retention during outpatient methadone detoxification treatment. Twenty male opiate addicts were randomly assigned to an experimental or control group. Following a 3-week methadone stabilization period, men in both groups received identical gradual methadone dose reductions during Weeks 4 through 9 and were maintained on placebo during Weeks 10 through 13. Beginning in Week 4, control patients received $5.00 for providing a specimen twice weekly. Experimental patients received $10.00 and a take home methadone dose for each opiate-free urine specimen but forfeited the incentives and participated in more intensive clinic procedures when specimens were opiate positive. The contingency management procedure slowed the rate of relapse to illicit opiate use. Experimental patients provided significantly more opiate-free urines during the methadone dose reduction in Weeks 4 through 9 than control patients, although the difference between groups was no longer significant during placebo administration in Weeks 10 through 13. In addition, the contingency management program improved treatment retention and reduced symptom complaints during the detoxification. The usefulness and limitations of contingency management procedures for outpatient methadone detoxification are discussed.     

BEHAVIORAL MANAGEMENT OF EXERCISE TRAINING IN VASCULAR HEADACHE PATIENTS: AN INVESTIGATION OF EXERCISE ADHERENCE AND HEADACHE ACTIVITY

A behavioral package was used to shape and maintain the adherence of 5 subjects with vascular headache to a program of aerobic exercise training. Repeated measures of exercise behavior were examined through the use of a bidirectional changing criterion design. Repeated measures of headache activity were also collected. Results demonstrated a functional relationship between the behavioral package and exercise adherence, because all 5 subjects showed exercise behavior that matched bidirectional changing exercise criteria. The results also indicated clinically significant collateral reductions in vascular headache activity in 4 subjects. Subjects whose aerobic fitness levels were not masked by vasoactive medication also showed measurable increases in aerobic fitness. The results are discussed in terms of the methodology used to demonstrate a functional relationship between the adherence package and exercise behavior and the possible mechanism(s) by which aerobic exercise activity might affect vascular headache activity.     

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.     

Characteristics of seriously emotionally disturbed youth with and without substance abuse in intensive case management

Youth with emotional disturbance who have substance abuse problems are of particular concern to child-serving agencies. Approximately 22% of the youth served in New York State's Intensive Case Management Program for Children and Youth (CYICM) have identified substance abuse problems. We compared youths enrolled in CYICM who abuse substances with those who do not abuse substances. Adolescents with substance abuse problems differed from non-abusing adolescents. The abusing cohort was most likely to be emancipated minors, not enrolled in school, less likely to be members of a minority group, and more likely to have private health care coverage. They also evidenced a different constellation of symptoms than the non-abusing cohort, with abusers tending to display suicidal symptoms and behaviors and sexual acting out. Abusers were also more likely to have been admitted to private psychiatric hospitals and to have had crisis contacts in emergency rooms. Similar to non-abusers, however, abusers spent significantly fewer days as inpatients in state hospitals, and had fewer admissions to these hospitals following their enrollment in CYICM.     

Validity and Application of Computer-simulated Scenarios in Personnel Assessment

In Germany computer-simulated scenarios have been applied in personnel management for several years. Their goals are either to assess how potential managers cope with complex and connected problem states (job aptitude testing aspect) or to provide feedback on manager strengths and weaknesses in dealing with complexity, and how to modify these when necessary (training aspect). This paper presents and evaluates those scenarios that have been subjected to validity studies.     

Emerging quality improvement measures in genetic counseling

The need to establish guidelines for total quality management in genetic counseling is now recognized as new genetic technologies are being introduced into genetics services and primary care. Genetic counselors have an important role in developing methods for assuring quality in the genetic counseling process. Emerging quality improvement measures as well as selected examples from the Quality Assurance Program in the Genetics Services Division at the Foundation for Blood Research are presented as examples of direct genetic counselor involvement. Suggestions for future directions of quality improvement activities for genetic counselors are discussed.     

Managing occupational stress: A national and international perspective

Theoretical models of occupational stress are important because they suggest a focus for intervention, and inform practice. The gap between research and practice was exposed most recently by Burke (1993) claiming little awareness of research findings by practitioners (managers, consultants, clinicians), little intervention activity being undertaken at the organizational level, little research being undertaken to determine the effectiveness of individual level interventions, and only modest use of work research findings for intervention and policy development (p. 85). This paper discusses the issue of intervention, and examines values, assumptions and the politics of applied research. A critical review of the evaluation studies of individual vs. organizational level interventions is undertaken and finally the problem of occupational stress as a national and international issue is considered.     

A TOKEN REINFORCEMENT PROGRAM IN A PUBLIC JUNIOR-HIGH SCHOOL1

In recent years, the technology of contingency management has been shown to be of increasing value in regular classrooms and public-school systems with both groups and individual pupils (Ayllon and Roberts, Journal of Applied Behavior Analysis, 1974, 7 , 71–76; Glynn and Thomas, Journal of Applied Behavior Analysis, 1974, 7 , 299–306; Lovitt and Curtiss, Journal of Applied Behavior Analysis, 1969, 2 , 49–53; Lovitt and Smith, Exceptional Children, 1974, 40 , 357–358; Medland and Stachnik, Journal of Applied Behavior Analysis, 1972, 5 , 45–51). In addition, established procedures are being systematically replicated across grade levels and differing subject-matter areas. A series of studies initiated by O'Leary and Becker (Exceptional Children, 1967, 33 , 637–642) form the basis for the present investigation. The token reinforcement program described by O'Leary and Becker (Exceptional Children, 1967, 33 , 637–642) was managed by the teacher of an adjustment class and involved 9-yr-old children described as emotionally disturbed. An elaborate replication of the 1967 O'Leary and Becker study conducted by O'Leary, Becker, Evans, and Saudargas (Journal of Applied Behavior Analysis, 1969, 2 , 3–31) with a grade-two class introduced several variables to examine their separate effects. The authors specified their treatment levels as baseline, classroom rules, educational structure, teacher praise and ignore, token I, withdrawal, token II, and follow-up. The present research modified the general design of O'Leary et al., (Journal of Applied Behavior Analysis, 1969, 2 , 3–31) to study how to maintain treatment effects. In the modification, rules were eliminated as a treatment variable because they are frequently associated with aversive practices in the school system, and it was deemed desirable to have mainly a positive orientation. A second difference was that the present subjects were grade-nine pupils functioning in the regular public-school system. The six students were older (average age = 16.2) and well behind their peers in achievement. They were considered behavior problems and as potential dropouts by teachers and counsellors. They were not considered to be emotionally disturbed. Finally, procedures designed to maintain behavior change generated by the token system were added. The operant level of unacceptable classroom behavior was obtained for six students receiving an individualized program of instruction in mathematics and science in a nonacademic grade-nine class in a public junior secondary school. Initially, two conditions (educational structure and praising appropriate behavior while ignoring inappropriate behavior) were introduced successively. Both procedures reduced inappropriate behavior slightly. When a token system, using backup reinforcers readily available in the school, was introduced in conjunction with the initial two conditions, inappropriate responses declined dramatically in all subjects. Withdrawal of the token program for a three-week period, leaving educational structure and praising and ignoring in effect, increased inappropriate behavior in five of the six subjects. The token program was then re-introduced in conjunction with contingency contracts. The result was a decline of inappropriate behavior below the mean of the first token condition for all subjects. Tokens were thinned and finally removed toward the end of this condition, leaving teacher praise and attention and the contract system in effect. Data obtained during a four-week followup indicated that the low level of inappropriate behavior was maintained in all subjects. This extension of the O'Leary et al., (Journal of Applied Behavior Analysis, 1969, 2 , 3–31) program, designed and implemented by the regular teacher, demonstrates that these procedures may be highly effective within the constraints found in an ordinary classroom in the junior secondary school.     

MANAGEMENT OF GERIATRIC INCONTINENCE IN NURSING HOMES

A behavioral management system designed to reduce urinary incontinence was evaluated in two nursing homes with a pretest-posttest control group design with repeated measures. The primary components of the system were prompting and contingent social approval/disapproval which required approximately 2.5 minutes per patient per hour to administer. The frequency of correct toileting for experimental subjects increased by approximately 45%. The experimental groups were significantly different from the control groups on both incontinence and correct toileting measures. The results are discussed in view of the management issues inherent in nursing home settings.