Real-world inpatient programs: Shedding some light-A critique

This critique is a response to an article by Morisse, Batra, Hess, Silverman, and Corrigan (1996), in which “a token economy for the real world” is promulgated as an alternative to the comprehensive social-learning program and assessment technology presented by Paul and Lentz (1977). The article misrepresents the treatment-and-assessment procedures that have been empirically validated as the most effective and cost-efficient for inpatient programs. The article also inappropriately cites the results of prior reports as support for an oversimplified approach to the development and implementation of inpatient programs. The promoted approach is in direct opposition to the widely recognized need for empirically validated interventions and evaluations in mental health services. Not only are data lacking to support assertions of effectiveness for the resulting program but illustrative examples demonstrate technically unsound procedures as well as an ethically questionable emphasis on staff desires to the exclusion of patient needs. We attempt to correct Morisse et al.'s inaccuracies and misconceptions regarding the work of Paul and colleagues, note the major problems with their perfunctory approach, and provide recommendations for implementation and maintenance of empirically validated procedures for inpatients.     

Predictors and moderators of improved social-emotional functioning in mothers with substance use disorders and their young children enrolled in a relationship-based case management program

Mothers with substance use disorders (SUDs) typically have trauma histories and psychosocial difficulties that lead to poor social-emotional functioning and disrupted mother–child relationships. This 12-month study explored associations of family adverse circumstances and services (case management, therapeutic, and community-based) received by 57-mothers with SUDs and their infants (less than 24-months-old) with changes in social-emotional functioning. All mothers were enrolled in a relationship-based case management program (Parent–Child Assistance Program [PCAP]) that emphasized connecting mothers to appropriate community services. A subset of mothers was additionally provided a trauma-focused psychotherapeutic intervention (infant–parent psychotherapy [IPP]). Dyads in both treatment groups improved in overall social-emotional functioning as assessed by the Functional Emotional Assessment Scale (FEAS). A combined-sample regression analysis revealed that improved FEAS scores were significantly predicted by the number of community services received but not by PCAP case management hours (IPP was not included in this analysis). More adverse circumstances were associated with less improvement in social-emotional functioning in the children; but among the mothers trauma level did not predict FEAS scores. We also found a moderating effect of trauma: Dyads with relatively more adversity showed a significantly greater association of community services received with improvement in FEAS scores than did those with relatively less adversity.     

L’analyse des risques psychosociaux en ESAT parmi des travailleurs en situation de handicap (TSH) : éléments de réflexion

Unlike the mainstream world of labour, studies on psychosocial risks (PSR) in Establishments and Work Assistance Services (ESAT) among workers with disabilities are scarce. Given the adverse effects of the PSR on both these workers and on the work itself, it seems essential to focus specifically on the PSR in the context of ESAT. The paper shows that the application of different theoretical models of PSR from the mainstream environment to the ESAT is possible. The health at work for people with disabilities requires taking into account the disorders influencing the identification and the mobilization of resources and skills. Working conditions in ESAT allow health promotion if they are adapted to the specificities and needs of people with disabilities.     

Demographic, Clinical, and Functional Characteristics of Youth Enrolled in Six California Systems of Care

We describe the demographic, functional, and clinical status of children served across six California counties implementing a longstanding integrated system of care approach called the California System of Care Model. The children enrolled in the care systems are an ethnically diverse group of predominantly pre-adolescent and adolescent males. The level of functional impairment and degree of symptomatology is high. Seventy to 80% of the youth were in the clinical or borderline clinical ranges as measured by the Child Behavior Checklist. Scores on the Child and Adolescent Functional Assessment Scale, provided by the treating clinician, indicated that up to 94% of the youth were in the moderate to severe levels of impairment. Children and adolescents rated themselves on the Youth Self Report as having lower levels of impairment than did parents. Caregivers and youth ratings emphasized externalizing rather than internalizing problems. Clinician ratings as captured by the CAFAS and the clinical diagnoses, presented a mix between internalizing and externalizing diagnoses and functional impairment areas. The six counties are serving children who have levels of impairment, similar to, or higher than, youth enrolled in other systems of care nationwide.     

Children with SED and Their Families in an Urban Public Mental Health System: Characteristics, Needs, and Expectations

We present information with implications for the design of comprehensive systems of care for children with severe emotional disturbance and their families. Combining quantitative data derived from children and caregivers on multiple standardized assessments and qualitative data based on the caregivers' personal comments, we provide a detailed account of child clinical status, service needs, involvement in normative childhood activities, aspects of family coping and functioning, and expectations of mental health services. Research participants were from a random sampling of children, 9 to 11 years of age, receiving an above average number of services from a large urban public mental health system. Results from this comprehensive needs assessment demonstrate the serious nature of the children's disabilities, illuminate the corresponding challenges for families, and provide direction for enhancing the system of care. The caregivers rated recreation and after school programs as their first priority. Since traditional mental health services are fairly well articulated and evolved, we concentrate on using information about child functioning and family context to inform the development of recreation and after school programs that can accommodate children with extremely challenging behaviors.     

Medicine as a career: Choices and consequences

Medicine has traditionally been regarded as a rewarding career both financially and socially. How true, however, is that tradition in today's world of rising costs and decreasing revenues? The educational debt of the physician-in-training is steadily increasing, and currently does not affect specialty choice. As the cost of medical education continues to rise, the applicant pool begins to shrink, thereby possibly affecting the quality of future physicians. Once the physician has completed training however, the majority enjoy a positive return on investment. Their incomes generally fail to remain ahead of inflation, and therefore, have remained within a narrow band of $40,000 in 1970 dollars. Finally, the demand for physician services cannot be attributed solely to either the consumer (patient) or to the supplier (physician). Rather, the demand for medical services appears to be a unique combination of the two. In conclusion, medicine still is an attractive career path, but the choices and consequences are becoming much more demanding.     

The future of genetics in public health

During the 1980s, we have witnessed an erosion in federal and state funding for the coordination of genetic services in state health departments. As this decade begins, the federal budget for the support of the national genetics program is less than half of the total available in 1980. In addition, priorities in state maternal and child health programs have changed, and genetic services have often received lower rankings aside of programs to improve prenatal care and to address problems such as teenage pregnancy. Clearly we are at a critical point for the future of genetics programs in the public health arena. Fortunately, despite the problems with funding and priority setting, important coalitions have been built during the past decade and continued advances in medical genetics have made it difficult for public health officials to ignore the potential impact of genetic services. Council of Regional Networks for Genetic Services (CORN) and the regional genetic services networks have provided opportunities for interaction and coordination between genetic services providers and public health officials that had not been available to any significant extent. The full potential of these coalitions has yet to be realized, but efforts in data collection, development of national guidelines and standards, and information sharing and networking have already had an influence on state genetic services programs. Continuing research on the genetics of chronic diseases and the influence of discoveries in molecular genetics will undoubtedly broaden the current scope of state public health programs in genetics, which all too often have been limited to newborn screening and administration of grants for genetic services. The regional and national genetic services programs should be strengthened and appropriate training programs should be developed in Schools of Public Health to provide the expertise and leadership that will be needed to guide the future of genetics in public health.     

Understanding Respite Care Use by Families of Children Receiving Short-Term, In-Home Psychiatric Emergency Services

Respite care is widely believed to be an important support service for families raising a child with a disability. We report the findings of a respite care utilization study conducted within the context of a larger research and demonstration project examining three models of intensive, in-home services for children experiencing psychiatric crises. Respite care, both in-home and out-of-home, was a support service available to families in two of the three study conditions. Overall, 34% of 146 eligible families used in-home and or out-of-home respite care. Utilization was lower than the estimates developed prior to implementation, prompting an inquiry at the end of the first project year designed to maximize use and to gather more information on caregiver and service provider attitudes toward respite care. The inquiry included caregiver and provider focus groups, surveys, and enhanced data collection and analysis. Caregiver interviews indicated that many families did not fully understand what it meant to receive respite care or even that it was available to them. A comparative analysis of respite care users and non-users revealed that respite care users were more likely to have younger children, children who had a greater number of assessed functional impairments, and fewer social supports. Respite care users also reported greater difficulty managing their children's difficult behaviors.