Applying Utilization Management Principles to a Comprehensive Service System for Children with Emotional and Behavioral Disorders and Their Families: A Feasibility Study

The Comprehensive Services Act for At Risk Youth and Families of Virginia (CSA), is a service, funding, and organizational reform initiative designed to improve the provision of child centered and family focused services within a community setting. We conducted this study in order to assess the feasibility of applying utilization management principles to the CSA in order to improve the appropriateness, quality, and cost effectiveness of this service delivery system. Data were gathered through focus groups, surveys, clinical profiling, and analysis of costs, and service utilization. While overall program costs increased since inception of the program, the costs per child served rose less than the rate of inflation. CSA appeared to be serving children with a high degree of emotional and behavioral difficulties. There was considerable variation among localities in placement patterns. A majority of survey and focus group respondents were willing to consider the application of utilization management principles to the CSA as long as decision making remained within localities. We concluded that there is a constructive role for utilization management approaches to improve the appropriateness and quality of services as well as enhancing efficiency in child mental health.     

Food and cocaine self-administration by baboons: effects of alternatives.

The effects of the availability of an alternative reinforcer on responding maintained by food pellets or drug solutions were examined in 8 adult male baboons (Papio hamadrayas anubis). During daily 23-hr experimental sessions, baboons had access to both food pellets and fluid under a two-choice procedure, in which the response requirement, under a fixed-ratio schedule, differed for the two commodities. There were no restrictions on access to water, which was continuously available from a spout at the rear of each cage. In Experiment 1, the fixed-ratio requirement, or cost, for fluid delivery remained constant while the fixed-ratio requirement for pellets was changed every 2 or 3 days when (a) no fluid, (b) a dilute dextrose vehicle, (c) 0.008 mg/kg per delivery cocaine, (d) 0.016 mg/kg per delivery cocaine, or (e) 0.032 mg/kg per delivery cocaine was available concurrently. In Experiment 1, progressively increasing the response requirement for pellets decreased pellet intake, but for 4 baboons pellet intake at maximum pellet cost was lower when cocaine, compared to the vehicle, was available. Increasing the response requirement for pellets had variable effects on vehicle intake. However, increasing the response requirement for pellets increased intake of at least one dose of cocaine to a greater extent than vehicle in all 8 baboons. Thus, cocaine could be considered a more effective economic substitute than vehicle for pellets. Experiment 2 systematically varied the order in which the response requirements for a pellet delivery were presented and added a control condition in which cocaine doses, yoked to the amount self-administered, were given three times during the session by the experimenter. Again, pellet intake at maximal pellet cost was lower when cocaine, compared to the vehicle, was available. In contrast, experimenter-given cocaine doses did not alter responding maintained by pellets. Thus, the effects of self-administered cocaine on responding maintained by food pellets differed from the effects of experimenter-given cocaine on responding maintained by food pellets.     

Reinforcement of compliance with respiratory treatment in a child with cystic fibrosis.

An 8-year-old boy with cystic fibrosis (CF), mental retardation, and autism exhibited noncompliance with respiratory treatments that were essential for the management of his CF. A treatment involving shaping cooperation while still allowing escape for aggression and avoidance behavior resulted in increases compliance with respiratory treatments and decreases in problem behavior. Treatment gains were maintained over 3 months.     

A case study of behavioral assessment and treatment of insect phobia

We assessed the academic performance of a 14-year-old boy with insect phobia in the context of feared stimuli. The dependent measure was math calculation rate across three conditions that varied therapist statements about the presence of crickets and the actual presence of live crickets. Subsequent treatment consisted of graduated exposure and contingent rewards for math problem completion. Assessment results indicated that the boy's performance was consistently low in the presence of live crickets but not when he was spuriously informed that crickets were present (the primary referral concern). Treatment results indicated no effect from exposure alone and a dramatic effect when exposure was combined with contingent rewards.     

Surviving death: how to refute termination theses

When deciding how ‘death’ should be defined, it is helpful to consider cases in which vital functions are restored to an organism long after those vital functions have ceased. Here I consider whether such restoration cases can be used to refute termination theses. Focusing largely on the termination thesis applied to human animals (the view that when human animals die they cease to exist), I develop a line of argument from the possibility of human restoration to the conclusion that in many actual cases, human animals continue to exist after they die. The line of reasoning developed here can be extended to show that other organisms survive death in many actual cases. This line of reasoning improves on other arguments that have been offered against termination theses. And if my argument regarding human animals surviving death is successful, then assuming that human persons are animals, we can also conclude that human persons in many actual cases continue to exist after death.     

Couple‐based Intervention for Depression: An Effectiveness Study in the National Health Service in England

This study represents an effectiveness study and service evaluation of a cognitive behavioral, couple‐based treatment for depression (BCT‐D) provided in London services that are part of the “Improving Access to Psychological Therapies” (IAPT) program in England. Twenty‐three therapists in community clinics were trained in BCT‐D during a 5‐day workshop, followed by monthly group supervision for 1 year. The BCT‐D treatment outcome findings are based on 63 couples in which at least one partner was depressed and elected to receive BCT‐D. Eighty‐five percent of couples also demonstrated relationship distress, and 49% of the nonclient partners also met caseness for depression or anxiety. Findings demonstrated a recovery rate of 57% with BCT‐D, compared to 41% for all IAPT treatments for depression in London. Nonclient partners who met caseness demonstrated a 48% recovery rate with BCT‐D, although they were not the focus of treatment. BCT‐D was equally effective for clients regardless of the clinical status of the nonclient partner, suggesting its effectiveness in assisting both members of the couple simultaneously. Likewise, treatment was equally effective whether or not both partners reported relationship distress. The findings are promising regarding the successful application of BCT‐D in routine clinical settings.     

Cognitive Behavioral Therapy and the Treatment of Posttraumatic Stress Disorder: Where Counseling and Neuroscience Meet

There is increasing evidence to support the biological basis of mental disorders. Subsequently, understanding the neurobiological context from which mental distress arises can help counselors appropriately apply cognitive behavioral therapy and other well‐researched cognitive interventions. The purpose of this article is to describe the neurobiological context underlying the formation and treatment of posttraumatic stress disorders, a mental disorder frequently encountered by counselors, from a cognitive therapy framework.     

Using high-probability foods to increase the acceptance of low-probability foods

Studies have evaluated a range of interventions to treat food selectivity in children with autism and related developmental disabilities. The high-probability instructional sequence is one intervention with variable results in this area. We evaluated the effectiveness of a high-probability sequence using 3 presentations of a preferred food on increasing acceptance in a child with autism who refused a few specific foods. The high-probability sequence increased acceptance of 3 foods. We then systematically faded the intervention for 2 foods.     

EFFECTS OF PREFERENCE AND REINFORCER VARIATION ON WITHIN-SESSION PATTERNS OF RESPONDING

We examined correspondence between preference assessment outcome and within‐session patterns of responding in one subject with autism. Responding maintained by a single highly preferred item resulted in a greater total number of responses, a slower decline in within‐session response rates, and a greater proportion of short interresponse times compared to responding maintained by varied moderately preferred (MP) stimuli. Presenting varied MP stimuli within the same session produced greater levels and more sustained responding than presenting those same stimuli individually.