In pursuit of inter-specialty consensus on excited delirium syndrome: a scoping literature review.

Excited delirium syndrome (ExDS) is a controversial and disputed diagnosis involving altered mentation, agitation, and, frequently, substance abuse. Recently, it has become a common pre-hospital diagnosis, serving as justification for use of force, restraint, and/or medication administration. To conduct a scoping review across three databases to describe the most frequently reported diagnostic criteria for ExDS, as well as to explore its use as a diagnosis for deaths of individuals in the custody of law enforcement. In 2021, three literature databases were searched: Ovid Medline, PsycInfo, and Scopus. Studies were included if they were peer-reviewed, English articles describing (1) ExDS symptoms, (2) substance intoxication with at least 2 ExDS symptoms present, or (3) centering on deaths occurring in the custody of law enforcement and attributed to ExDS. Key study data were extracted and the current literature was described qualitatively. Analysis took place between March and December 2021. A total of 97 studies were identified through initial abstract and secondary full-text review, with noted discrepancies in the definition of ExDS itself. After review, differences in ExDS diagnosis among organizations were explored, along with subsequent clinical impact, particularly in the pre-hospital setting. Resulting impact on patients, particularly those of minoritized ethnic and racial groups, was also noted. Prone aggressive restraint, in particular, is noted as an established risk factor for fatalities in ExDS cases. At this time, ExDS should not be utilized as a diagnosis; major medical organizations have an urgent responsibility to convene to formalize consensus-based diagnostic criteria or to propose alternate management guidelines for agitated and altered persons.

Reducing distress and depression in cancer patients during survivorship.

OBJECTIVE: Distress and depression are prevalent in cancer patients throughout survivorship and are associated with adverse outcomes. This study examines the association between outpatient psycho-oncology treatment and distress and depression in cancer patients. METHODS: This is a prospective observational study of adult patients with a primary diagnosis of cancer referred for psycho-oncology services. Patients were seen for two psycho-oncology visits in a single clinical setting with various qualified providers. Patients completed the distress thermometer and problem checklist (DT + PL) and the Patient Health Questionnaire (PHQ-9) at the beginning of their first and second visits and repeated the DT at the end of these visits. RESULTS: The analysis included 174 patients seen once and 69 patients seen twice. Patients were seen on average 2.5 years after diagnosis. Both visits were associated with significant reductions in distress (5.56 before and 3.85 after for visit 1, p < 0.001; 4.92 before and 3.43 after for visit 2, p < 0.001). There was a significant reduction in distress from baseline to after visit 2 (p < 0.001). Depression scores significantly decreased from the first to second visits (8.79-7.57; p = 0.002). CONCLUSIONS: Psycho-oncology services were associated with significant reductions in distress and depression, with scores after services no longer meeting criteria for clinically significant distress (DT scores ≥ 4) and depression (PHQ-9 scores ≥ 8) as they did at baseline. Reductions in distress and depression were not significantly associated with provider type, intervention or timing of diagnosis. These findings support the use of psycho-oncology services in cancer patients throughout survivorship.

Organizing Eldercare for Geographic Communities.

The dramatically increasing prevalence of elderly persons disabled by conditions associated with aging could motivate reexamination of service delivery and financing for this population, seeking quality, reliability, and efficiency. Research and innovation have established many components of effective reforms, such as patient-directed care planning, encouragement of volunteer networks and family caregiving, mobilizing services to the home, adhering to patient goals and priorities, limiting poly-pharmacy, reducing the risk of falls, and providing adequate support services for people with disabilities. However, none have become widespread and rarely, if ever, are all of the evidence-based improvements available to a particular disabled elder. This essay argues that reform for disabled elders should be anchored in geographic communities, with a new organizational entity having responsibility for measuring performance and implementing improvements. This entity would use data and public input to set priorities, test improvement strategies, and take steps to assure adequate workforce and service supply. In this MediCaring Community, sustaining finances could come from local taxes or capturing the savings in Medicare that arise with optimal comprehensive services. Generating a new structure to monitor and manage eldercare services for a geographic community would be readily accomplished in some communities and would be worth testing.

Conversion Disorder in an Appalachian Community.

OBJECTIVES: Conversion disorder (CD) is believed to be the manifestation of physical and/or neurological symptoms for primary gain without an identifiable organic cause. Although it is believed to be more common in rural areas, the literature examining this claim is sparse. To our knowledge, no study has been published evaluating the prevalence of CD in a rural Appalachian population. The aim of this study was to characterize and determine the prevalence of CD per Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, criteria in a rural Appalachian psychiatric consultation service and to compare this population with control patients from the same service. METHODS: We performed a retrospective chart review of all patients diagnosed as having CD per Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, criteria on a psychiatric consultation service at a rural Appalachian academic medical center during a 13-month time period. For each case, two consecutive control patients were selected from the same service and time span. RESULTS: There were 21 cases and 42 controls in this study, with a CD prevalence rate of 6.0% (N = 21/351). Sociodemographic, comorbidity, and recent symptomatology data were obtained. Compared with controls, cases were significantly younger and were more likely to have a history of sexual abuse, seizure disorder, antiepileptic use, neurologic referral, electroencephalogram, magnetic resonance imaging of the brain, and history of CD. We found it interesting that fewer cases reported alcohol and drug use. CONCLUSIONS: The observed prevalence of 6.0% does not support the historical theory that CD is more prevalent in rural or lower socioeconomic populations. Our data add to the characterization of the Appalachian CD population.

Descriptive characteristics of extinction bursts: A record review.

Procedural extinction is sometimes associated with a temporary increase in responding known as an extinction burst. Extinction bursts present unique challenges in the context of treating behavior targeted for reduction. The present study updates the prevalence of extinction bursts using a clinical sample (N = 108) receiving treatment for targeted behavior. The prevalence of extinction bursts in our sample (24%) was consistent with that in prior literature. The extinction-burst magnitude decreased across sessions after extinction was contacted during treatment, but this sample did not demonstrate decreased persistence or magnitude of extinction bursts across successive transitions from baseline to treatment. We also examined the prevalence and magnitude of extinction bursts based on the function and topography of targeted behavior and treatment components and found no consistent relation among these variables. These findings should lead clinicians to prepare for transient extinction bursts when implementing extinction-based treatment for challenging behavior.

Expanding a laboratory model for evaluating relapse of caregiver nonadherence.

Caregiver adherence to treatment plans is likely maintained by negative reinforcement and can contact extinction when child responding relapses. When caregiver adherence contacts extinction, caregiver nonadherence, such as reinforcing their child's challenging behavior, relapses, threatening treatment efficacy. Previous laboratory models demonstrating the relapse of caregiver nonadherence only evaluated treatment for behavior maintained by social-positive reinforcement, not that maintained by social-negative reinforcement. These models only measured caregiver nonadherence as discrete events, which cannot capture the magnitude of each error. The present study was an evaluation of the relapse of caregiver nonadherence during simulated treatments for escape-maintained challenging behavior. First, caregivers placed demands in a home-like setting and a research confederate responded to these demands in a manner mimicking clinical clients. Next, caregivers were taught to implement treatment in a clinical setting and the confederate's behavior gradually improved. Last, caregivers returned to the home-like setting and confederate challenging behavior relapsed. Nonadherence relapsed for all caregivers, demonstrating the need for additional research on methods for mitigating caregiver relapse during treatment of children's challenging behavior and the usefulness of the proposed measurement system for future research.

Evaluation of schedule thinning following treatment for aggression maintained by access to higher level restrictive and repetitive behavior.

One of the diagnostic characteristics of individuals with autism spectrum disorders includes engaging in restricted and repetitive behavior. Research has shown that individuals will often display problem behavior when access to restricted and repetitive behavior is blocked. The purpose of the current study was to evaluate the use of functional communication training and schedule thinning to treat aggression displayed by three children diagnosed with autism spectrum disorders when higher level restrictive and repetitive behavior was blocked. Further, we assessed whether all steps in a schedule-thinning sequence were necessary as well as extended the practicality of these procedures by removing the continuous signal during the delay to reinforcement. The results indicated that functional communication with schedule thinning reduced aggression related to blocking access to engaging in higher level restrictive and repetitive behavior for all participants.

Assessing Preference in a Paired-Stimulus Arrangement with Captive Vultures (Aegypius Monachus).

Vultures play an important role in our ecosystem by filtering out bacteria and viruses harmful to humans (e.g., rabies, botulism). However, many vultures remain in human care due to skill deficits and behavioral excesses, which can be treated using behavior-management practices that rely on effective (often edible) reinforcers. The current study replicated the forced-choice or paired-stimulus preference assessment with five birds of prey. Across all vultures, participants displayed a preference for animal (e.g., meat) over nonanimal stimuli (e.g., fruit), and mice meat was the most preferred edible for 4 of the 5 vultures. The application of this methodology to birds of prey might allow rehabilitators, conservationists, and other caretakers to make greater gains in training vultures to both acquire new skills and decrease problem behavior using highly preferred edible items.

Teaching Children to Respond to Questions About the Past: A Preliminary Analysis.

Correct responding to questions regarding events that have occurred in the past are important for conversations and safety. Limited research has demonstrated techniques for teaching this skill to children who do not successfully tact past events. The current study demonstrates a probe-fading method for teaching children to correctly tact stimuli they were exposed to in the past. Initially, experimenters asked a question about the item the participant has interacted with immediately after item engagement. Subsequently, experimenters systematically increased the time between participants interacting with an item and the question until participants mastered accurate reporting after a 30-min delay. Future directions when teaching delayed reporting are summarized.

Differences in Utilization of Perinatal Psychiatric Teleconsultation Line Between Primary Care and Mental Health Providers.

PURPOSE: Teleconsultation has been a newly recognized avenue by which to provide psychiatric services to perinatal populations being treated either by psychiatric or primary care providers. The Periscope Project (TPP) is a business-hours teleconsultation line providing enrolled clinicians with access to a subspecialty-trained psychiatrist, as well as community resources and provider education. This study examines the differences in consultation between enrolled providers. METHODS: Encounter data was entered into REDCap by TPP's team members. Data was analyzed using summary statistics. Satisfaction information was attained by follow-up survey. RESULTS: During the first 24 months of program activity, TPP had a total of 737 referred encounters, 70.4% from primary care and 20.5% from psychiatry. There were statistically significant differences between psychiatric and primary care providers in terms of recommendations for use of certain types of medications and use of diagnostic screenings, as well as differences in what providers would have recommended in absence of TPP's involvement. CONCLUSIONS: Differences in enrollee's rationale for consultation allows for better understanding of the needs of front-line providers. Tailoring educational information and even teleconsultation information based on provider group can allow for more efficient patient care and resource utilization. Providers across the spectrum found TPP beneficial, indicating that continued availability to all providers caring for women of reproductive age is important.

The stability of function of automatically reinforced vocal stereotypy over time.

Although prior research has suggested the function of socially reinforced problem behavior can change across time, the stability of the function of automatically reinforced behavior is largely unknown. Further, some authors have suggested automatically reinforced behavior is likely to enter into socially mediated contingencies. The present study compared 2 functional analyses conducted on the same target behavior at least 1 year apart. Participants were 6 individuals diagnosed with an intellectual or developmental disability displaying automatically reinforced vocal stereotypy. Results indicated the function of each participant's vocal stereotypy remained stable over time (i.e., no new functions were acquired); however, future research on functional stability for automatically reinforced behavior of other topographies is needed.

Functional analysis and treatment of self-injurious feather plucking in a black vulture (Coragyps atratus).

The etiology and maintenance of self-injurious feather plucking (FP) have been attributed to biological and environmental processes, yet a definitive solution has not been found. The current study investigated the application of a functional analysis and function-based treatment to reduce the FP of a black vulture (Coragyps atratus). FP was found to be maintained by positive reinforcement in the form of contingent attention. A treatment consisting of noncontingent reinforcement decreased FP, and levels of FP remained low during schedule thinning. The current study further demonstrates the validity of function-based assessment and treatment with captive animals.

Effects of delayed time-out on problem behavior of preschool children.

Time-out is a common negative punishment procedure in home and school settings. Although prior studies have shown time-out is effective, more research is needed on its effects when implementation is imperfect. We evaluated delays to time-out with 4 preschool children who engaged in some combination of aggression, property destruction, and rule breaking. Target behavior decreased for all subjects exposed to delayed time-out, with 3 of 4 subjects displaying low levels of target behavior even when time-out was delayed by 90-120 s. These data suggest delayed time-out might be effective in situations in which a caregiver or teacher cannot implement time-out immediately.

Retrospective analysis of changes in response topographies of escape-maintained aggressive behavior during functional analyses.

We observed changes in the rates of response topographies during the demand condition of functional analyses for participants who demonstrated problem behavior maintained by escape. Over the course of the functional analysis for each participant, the number of topographies decreased from the first to the last session. Additionally, after the first session of the demand condition the rate of responding for one topography increased or remained at high levels while the rates of all other topographies decreased. The implications of these results when conducting functional analysis are discussed.

A multicomponent approach to thinning reinforcer delivery during noncontingent reinforcement schedules.

We evaluated a noncontingent reinforcement procedure that involved initially providing three subjects with signaled, continuous access to the functional reinforcer for aggression and slowly increasing the amount of time subjects were exposed to the signaled unavailability of the reinforcer. Additionally, alternative potential reinforcers were available throughout the sessions. Results showed immediate and substantial reductions in aggression for all three subjects. The clinical utility of this intervention is discussed, and future research directions are recommended.

A comparison of positive and negative reinforcement for compliance to treat problem behavior maintained by escape.

Previous research has shown that problem behavior maintained by escape can be treated using positive reinforcement. In the current study, we directly compared functional (escape) and nonfunctional (edible) reinforcers in the treatment of escape-maintained problem behavior for 5 subjects. In the first treatment, compliance produced a break from instructions. In the second treatment, compliance produced a small edible item. Neither treatment included escape extinction. Results suggested that the delivery of a positive reinforcer for compliance was effective for treating escape-maintained problem behavior for all 5 subjects, and the delivery of escape for compliance was ineffective for 3 of the 5 subjects. Implications and future directions related to the use of positive reinforcers in the treatment of escape behavior are discussed.

Comparing acquisition of exchange-based and signed mands with children with autism.

Therapists and educators frequently teach alternative-communication systems, such as picture exchanges or manual signs, to individuals with developmental disabilities who present with expressive language deficits. Michael (1985) recommended a taxonomy for alternative communication systems that differentiated between selection-based systems in which each response is topographically identical (e.g., card selection and exchange systems) and topography-based systems in which each response is topographically distinct (e.g., signed language). We compared the efficiency of training picture exchanges and signs with 3 participants who presented with severe language deficits; all participants acquired the picture-exchange responses more readily.

Using a blocked-trials procedure to teach identity matching to a child with autism.

Children with autism may struggle in developing conditional discrimination repertoires. Saunders and Spradlin (1989, 1990, 1993) arranged "blocked" teaching trials in which they presented the same sample stimulus repeatedly across trials (in lieu of randomly alternating targets across trials) and then faded the number of trials in each block. We replicated the effects of this blocked-trials procedure in teaching identity matching to a child with autism and evaluated the necessity of fading. Arranging blocked trials facilitated the acquisition of identity matching, but fading the block size was not necessary to maintain discriminated performance.

An assessment of the efficiency of and child preference for forward and backward chaining.

Comparative studies of forward and backward chaining have led some to suggest that sensitivity to each teaching procedure may be idiosyncratic across learners and tasks. The purposes of the current study were threefold. First, we assessed differential sensitivity to each chaining procedure within children when presented with multiple learning tasks of similar content but different complexity. Second, we evaluated whether differential sensitivity to a chaining procedure during a brief task predicted differential sensitivity during the teaching of longer tasks. Third, we directly assessed children's preferences for each teaching procedure via a concurrent-chains preference assessment. Learners acquired all target skills introduced under both chaining conditions, but individual children did not consistently learn more efficiently with either procedure. Short-duration tasks were not predictive of performance in tasks of longer duration. Both chaining procedures were preferred over a baseline condition without prompting, but participants did not demonstrate a preference for either procedure.