Assertiveness in physicians' interpersonal professional encounters: A scoping review.

PURPOSE: Good relationships between physicians, patients, families and the healthcare team are essential for high-quality care. Medical encounters are sometimes challenging. They may include conflicts, requiring physicians to be assertive: that is to share and protect their needs, rights and values while preserving those of others. Whereas assertiveness has been studied in patients and nursing staff (those with less power in healthcare), physicians' assertiveness, which must be mindful of these power differences, lacks a comprehensive review. Thus, this scoping review focuses on assertive communication in physicians' encounters. METHODS: A literature search of four online databases: MEDLINE, Embase, PsycINFO and WoS, seeking articles on physicians' assertiveness as a communication style published until February 2022. The Joanna Briggs Institute approach and the Preferred Reporting Items for Systematic Reviews checklist underpinned the review protocol. RESULTS: We identified 1513 articles relating to assertiveness, reviewed 153 full-text articles and selected 22 for full review, 68% from the last decade. The articles focused mainly on assertive communication and relationships with medical staff, with 54% focusing on bottom-up power relations. In 40% of the articles, no clear definition of assertiveness was included. Definitions included had varied focus: on self, on the other or both. Overall, assertiveness measures varied widely, precluding a methodical comparison. CONCLUSIONS: Despite the growing interest in physicians' assertiveness, a clearer definition and in-depth exploration of assertiveness are needed alongside development of valid measures of assertiveness appropriate to physicians. Based on the review, we offer a relational definition of assertiveness as the capacity to communicate one's views, concerns, rights and needs while respecting others and preserving therapeutic, collegial and educational professional alliances. This definition may serve to expand research in the field while offering a professional alternative to problematic communication styles-passive and self-denying or paternalistic and aggressive -that obfuscate and thus undermine physician-patient relationships.

The hidden curriculum of breaking bad news: Identification of three dimensions and four communication patterns.

OBJECTIVES: To explore students' observations in the hidden curriculum of physicians' breaking bad news interactions and identify dimensions and patterns within them. METHODS: We qualitatively analyzed 156 written narrative descriptions of bad news encounters in the clinics written by senior medical students. RESULTS: The analysis identified three dimensions within the encounters: providing information, dealing with emotions, and discussing treatment plans. These dimensions were observed in different proportions, identifying four communication patterns. Half of the encounters focused solely on presenting a treatment plan. Within them, the news was communicated abruptly while neglecting to share information or address emotions. CONCLUSIONS: Compared to the main literature on breaking bad news that focuses on two dimensions-the present study identified a third, prominent dimension-discussing the treatment plan. Half of the hidden curriculum experiences contradict the taught protocol, paying little/no attention to emotion and information. PRACTICE IMPLICATIONS: When teaching breaking bad news, it is essential to address the day-to-day practices students' observe. Students exposed to these encounters might misinterpret the physician's reliance on a single dimension as best practice. To mitigate this and help recognize their and others' tendency to focus primarily or solely on one dimension, we suggest a simple reflective prompt.

A New Tool for Determining and Monitoring Public Healthcare Systems.

The challenge of maintaining a standard of treatment has become a core issue due to the COVID-19 outbreak, and many countries are currently addressing this issue. Since public health policymaking is a multidimensional issue, including different aspects, measures, features, and scales, and so forth, multidimensional definitions of reasonable medical treatments may improve planning and performance standards for public health systems. This study emphasizes the need to settle all of the dimensions in policymaking to aim to elicit reasonable medical treatment definitions and adequacy assessments from diverse healthcare stakeholders and offer a universally applicable reasonable medical treatment formula. Interviews of thirty-two stakeholders were qualitatively analyzed and mapped onto an innovative quadrilateral model. The findings showed that most interviewees viewed the system positively. However, they identified various lacunas-clinical/service, social/ethical, legal, and economically reasonable medical treatment aspects. A generic formula for the medical sub-services' activity accounted for these, given any specific time period and technological development. The stakeholders' positive assessment reflects an acquiescence for resource allocation and policy enforcement, rather than optimal healthcare. Nationally, this should be addressed. The quadrilateral mapping of the stakeholders enhances the translatability and generalizability of the systemic data. A comprehensive reasonable medical treatment formula will help the policymakers to optimize services, and it will render healthcare planning/implementation transparent, effective, and responsible.

The comorbidity between autism spectrum disorder and post-traumatic stress disorder is mediated by brooding rumination.

LAY ABSTRACT: Autism spectrum disorder is a neurodevelopmental condition characterized by social communication difficulties and restricted repetitive behaviors. Individuals with autism spectrum disorder are often diagnosed with other psychiatric conditions, including attention deficit hyperactivity disorder, anxiety, and depression. However, research on post-traumatic stress disorder among individuals with autism spectrum disorder is scarce. Nonetheless, studies have shown that those with autism spectrum disorder may face an increased risk of exposure to traumatic events. Separate lines of research in autism spectrum disorder and post-traumatic stress disorder have shown that the two may share several vulnerability factors. One of those is ruminative thinking, that is, one's tendency to re-hash thoughts and ideas, in a repetitive manner. This article examined the role of two rumination types as potential factors connecting autism spectrum disorder and post-traumatic stress disorder: brooding (continuously comparing one's current condition to one's desired condition) and reflection (an introspective effort to cognitively solve one's problems). A total of 34 adults with autism spectrum disorder (with no intellectual impairment) and 66 typically developing adults completed questionnaires assessing post-traumatic stress disorder symptoms and rumination. The results showed increased post-traumatic stress disorder symptoms in adults with autism spectrum disorder, compared to typically developing adults. Brooding rumination was also higher among those with autism spectrum disorder. Finally, brooding, but not reflection, served as a mechanism connecting autism spectrum disorder and post-traumatic stress disorder, that is, those with autism spectrum disorder showed increased brooding, which in turn predicted more post-traumatic stress disorder symptoms. This study has potential clinical implications. Rumination and cognitive inflexibility, which are common in autism spectrum disorder, could exacerbate post-traumatic symptoms among individuals with autism spectrum disorder who experience traumatic events. Interventions targeting brooding rumination and cognitive flexibility may assist in alleviating post-traumatic symptoms in individuals with autism spectrum disorder.

Addressing the Needs of Preschool Children in the Context of Disasters and Terrorism: Assessment, Prevention, and Intervention.

PURPOSE OF REVIEW: The goal of this paper is to review the research literature regarding the needs of preschoolers in the context of disasters and terrorism with the aim of understanding the existing methods for assessment, prevention, and intervention to provide recommendations and point out required research and development. RECENT FINDINGS: We differentiate between screening tools that provide initial evaluation and assessment tools for diagnosing preschooler children's pathology and review possible interventions that address the preschool child's needs before, during, and after the incident itself. We also emphasize the lack of dissemination and research of prevention programs and mass interventions for preschoolers. Programs for community mass prevention and intervention for preschoolers should be developed and evaluated and interventions should be adapted for individual and group delivery. Moreover, the increase in the number of children refugees requires cultural adaptations of assessment measures and interventions.

Addressing the Needs of Preschool Children in the Context of Disasters and Terrorism: Clinical Pictures and Moderating Factors.

PURPOSE OF REVIEW: This paper surveys the existent theoretical and research literature regarding the needs of preschool children in the context of disasters and terrorism with the aim of understanding (a) the consequences of such events for young children and (b) the main moderating variables influencing the event-consequence association to learn how to enhance their resilience. RECENT FINDINGS: Consequences include a variety of emotional, behavioral, and biological outcomes. Implications for refugee children are discussed. Main moderating variables were mother's sensitivity and mother's PTSD symptoms. Exposure to disasters and terrorism may have severe effects on the mental health and development among preschool children. Future research should explore the implications of different levels of exposure and the effects of moderating psychosocial and biological variables, including the parent-child triad, on the event-consequence relationship.

Social (Pragmatic) Communication Disorder and Its Relation to the Autism Spectrum: Dilemmas Arising From the DSM-5 Classification.

DSM-5 introduced two diagnoses describing neurodevelopmental deficits in social communication (SC); Autism Spectrum Disorder (ASD) and Social (Pragmatic) Communication Disorder (SPCD). These diagnoses are differentiated by Repetitive and Restricted Behaviors (RRB), required for an ASD diagnosis and absent in SPCD. We highlight the gaps between the research into SPCD and DSM-5's diagnostic criteria, and discuss the clinical implications of this diagnostic decision. We argue that DSM-5's demand for full manifestation of both SC and RRB axes when diagnosing ASD, prematurely forced a categorical view on the continual nature of the potentially dependent SC and RRB phenotypes. We conclude by highlighting the implications of this differential diagnostic decision on public health policies, designated therapy, and the need for further research regarding SPCD.

Enhancing Children's Resilience in Schools to Confront Trauma: The Impact on Teachers.

BACKGROUND: Children's exposure to stressful events requires effective interventions to strengthen adaptive development. Expanding the teachers' role to deliver resilience-focused interventions has been shown to enhance children's coping and to have a positive impact on the teachers themselves. METHOD: This study compared the self-efficacy and perceived performance of 48 teachers following the implementation of such an intervention with 52 control teachers. RESULTS: Trained teachers reported higher self-efficacy and perceived performance. Associations between years of experience, perceived performance and self-efficacy are discussed. CONCLUSIONS: This study provides further evidence on the positive impact of teacher-delivered interventions on teachers' performance and self-efficacy. Future studies should replicate this design with a larger sample to examine stages of professional experience, grades, before-after measures, association with students' coping and include male teachers.

Self-regulated compliance in preschoolers with autism spectrum disorder: The role of temperament and parental disciplinary style.

Regulatory difficulties are common in children with autism spectrum disorder. This study focused on an important aspect of self-regulation-the ability to willingly comply with frustrating demands of socialization agents, termed "self-regulated compliance." We studied compliance to parental demands in 40 preschoolers with autism spectrum disorder and 40 matched typically developing preschoolers, during separate interactions with mother and father, while engaging in two paradigms: toy pick-up and delayed gratification, which tap the "do" and "don't" aspects of self-regulated socialization at this age. Parents' disciplinary style was micro-coded from the two paradigms and child temperament was parent reported. Compared to their typically developing peers, children with autism spectrum disorder showed more noncompliance and less self-regulated compliance to parental demands and prohibitions and greater temperamental difficulties across several domains. No group differences were found in parental disciplinary style. Child self-regulated compliance was associated with parental supportive disciplinary style and with child attention focusing. Findings highlight the importance of parental supportive presence in structuring the development of socialization in children with autism spectrum disorder. Implications for parent-child emotion regulation interventions are discussed.

Assessing the Use of the Child Attachment Interview in a Sample of Israeli Jewish Children.

BACKGROUND: This manuscript assesses the use of the Child Attachment Interview (CAI) in a sample of Israeli Jewish children in middle childhood in order to add to empirical data on this measure. METHOD: Forty-one children between the ages of 7 and 13 were consecutively recruited to the study. The clinical sample included 29 children diagnosed with anxiety disorder, major depression or ADHD. The Father Focused Referral (FFR) sample included 12 children whose father was unavailable to them. Participants were administered the CAI and coded by certified personnel. RESULTS: 81.4% concordance was found between maternal and paternal secure-insecure attachment classifications in the clinical sample; 100% of the children in the FFR group were classified as insecurely attached to their fathers suggesting convergent validity for the classification of father attachment; 45.4% of the children in the FFR sample were also classified as insecurely attached to their mothers, pointing to the difference that can be found between the two parental attachment classifications in relevant cases, and therefore to sufficient discriminant validity between the two classifications. CONCLUSIONS: The clinical sample concordance rate, which was lower than in previous studies, indicates that parental concordance rates should be further investigated using different samples and countries. The study's findings regarding the difference that can be found between parental attachment classifications show the instrument's relevance in cases which the parental representations may differ. In these cases, using an instrument that does not examine the attachment toward both parents might not suffice. Study limitations and further implications are discussed.

Preschool Israeli Children Exposed to Rocket Attacks: Assessment, Risk, and Resilience.

Preschool children are among the most vulnerable populations to adversity. This study described the effects of 4 weeks of daily exposure to rocket attacks on children living on Israel's southern border. Participants enrolled in this study were 122 preschool children (50% boys) between the ages 3 and 6 years from 10 kindergartens. We assessed mothers' report of children's symptoms according to the DSM-IV and alternative criteria resembling the DSM-5 criteria for posttraumatic stress disorder (PTSD), general adaptation, traumatic exposure, and stressful life events 3 months after the war. The prevalence of PTSD was lower when the diagnosis was derived from the DSM-IV (4%) than from the DSM-5 criteria (14%). Mothers of children with 4 or more stressful life events reported more functional impairment in social, occupational, and other important areas of functioning compared to children with 0 or 1 stressful life event. Children with more severe exposure showed more severe symptoms and mothers had more concerns about the child's functioning (η(p)(2) = .09-.25). Stressful life events and exposure to traumatic experiences accounted for 32% of the variance in PTSD and 19% of the variance in the adaptation scale. Results were explored in terms of risk and resilience factors.

Self- and Co-regulation of Anger and Fear in Preschoolers with Autism Spectrum Disorders: The Role of Maternal Parenting Style and Temperament.

Emotion regulation (ER) difficulties are a major concern in children with autism spectrum disorder (ASD). Maternal temperament and parenting style have significant effects on children's ER. However, these effects have not been studied in children with ASD. Forty preschoolers with ASD and their mothers and forty matched controls engaged in fear and anger ER paradigms, micro-coded for child self- and co-regulatory behaviors and parent's regulation-facilitation. Mothers' parenting style and temperament were self-reported. In the ASD group only, maternal authoritarian style predicted higher self-regulation and lower co-regulation of anger and maternal authoritative style predicted higher self-regulation of fear. Maternal temperament did not predict child's ER. Findings emphasize the importance of maternal flexible parenting style in facilitating ER among children with ASD.

Effects of ethnicity on sub-clinical PTSD and depressive symptoms, following exposure to missile attacks in Israel--a pilot study.

OBJECTIVE: The aim of this pilot study was to compare the occurrence of post-traumatic stress disorder (PTSD) symptoms, major depression disorder (MDD)-related symptoms, and negative mood regulation capacities among Israeli Jewish and Arab children and their parents, all of whom had been exposed to recurrent missiles attacks during the Second Lebanon War. METHODS: Participants consisted of 28 Jewish and 14 Arab children (aged 4-18 years) and their parents. They were assessed by self-report instruments and a semi-structured interview (K-SADS-PL). RESULTS: Among children, PTSD and depressive symptoms were found to be interrelated. Parents' depression and mood regulation were found to be related to their children's PTSD and depressive responses. Both children's and parents' negative mood regulation capacities were inversely related to children's depressive and PTSD symptoms. Both Jewish and Arab children's scores on the Children Depression Inventory (CDI) and on the PTSD Scale Symptoms Interview (PSS-I) showed significant levels of emotional distress following the missile attacks. However, Arab children reported significantly higher levels of PTSD and depressive symptoms in comparison to Jewish children. CONCLUSION: Ethnicity seems to be an important factor in children's responses to war-related events.

The role of the precuneus in metaphor comprehension: evidence from an fMRI study in people with schizophrenia and healthy participants.

Comprehension of conventional and novel metaphors involves traditional language-related cortical regions as well as non-language related regions. While semantic processing is crucial for understanding metaphors, it is not sufficient. Recently the precuneus has been identified as a region that mediates complex and highly integrated tasks, including retrieval of episodic memory and mental imagery. Although the understanding of non-literal language is relatively easy for healthy individuals, people with schizophrenia exhibit deficits in this domain. The present study aims to examine whether people with schizophrenia differentially recruit the precuneus, extending to the superior parietal (SP) cortex (SPL), to support their deficit in metaphor comprehension. We also examine interregional associations between the precuneus/SPL and language-related brain regions. Twelve people with schizophrenia and twelve healthy controls were scanned while silently reading literal word pairs, conventional metaphors, and novel metaphors. People with schizophrenia showed reduced comprehension of both conventional and novel metaphors. Analysis of functional connectivity found that the correlations between activation in the left precuneus/SPL and activation in the left posterior superior temporal sulcus (PSTS) were significant for both literal word pairs and novel metaphors, and significant correlations were found between activation in the right precuneus/SPL and activation in the right PSTS for the three types of semantic relations. These results were found in the schizophrenia group alone. Furthermore, relative to controls, people with schizophrenia demonstrated increased activation in the right precuneus/SPL. Our results may suggest that individuals with schizophrenia use mental imagery to support comprehension of both literal and metaphoric language. In particular, our findings indicate over-integration of language and non-language brain regions during more effortful processes of novel metaphor comprehension.

Post-traumatic reaction of Israeli Jewish and Arab children exposed to rocket attacks before and after teacher-delivered intervention.

BACKGROUND: Belonging to ethnic minorities is a risk factor for traumatized children. this study investigated the influence of exposure to rocket attacks during the 2006 Lebanon War on Jewish and two groups of arab Israeli students and the effect of implementing a teacher-delivered intervention focusing on resilience enhancement. METHOD: Children from both ethnic groups (N = 1,372) were assessed for stressful life events, symptoms and parental concern regarding adaptation before the 16- week program (t1) and after its completion (t2). RESULTS: arab children reported more severe symptoms at t1. the three groups showed a significant decrease to the same level at t2. Both ethnic groups differed in the level of parental concern and in the way stressful life events affected children's symptoms. CONCLUSIONS: the results suggest that school-based programs with teachers as clinical mediators could be a valuable, cost-effective cross-cultural model of intervention after mass trauma, moderating vulnerabilities of ethnic minorities.

Platelet vesicular monoamine transporter 2 density in the disruptive behavior disorders.

In a former study, we reported decreased platelet vesicular monoamine transporter 2 (VMAT2) density (Bmax) in patients with ADHD. The current study aimed at measuring platelet VMAT2 in the disruptive behavior disorders (DBDs) to assess whether this finding is specific to ADHD or generalizable to the broader DBD concept. The study included 13 patients with DBDs aged 10-12 years and 16 healthy volunteers aged 8-17 years. All participants underwent a thorough clinical evaluation using Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version for diagnosis, the Nisonger Child Behavior Rating Form, the Clinical Global Impressions Scale-Severity version, and the DSM-IV ADHD Scale (DAS). The study group's DAS scores did not differ from those of the control group. There was no significant difference between the patients with DBDs and the control group either in VMAT2 density (Bmax) or affinity (Kd) as measured by high-affinity [(3)H]TBZOH binding. We conclude that the formerly reported decreased platelet VMAT2 Bmax in patients with ADHD may be specific to ADHD and not present in DBDs. Larger-scale replication is needed.

Teacher-delivered resilience-focused intervention in schools with traumatized children following the second Lebanon War.

The 2006 Lebanon War exposed children in the north of Israel to daily rocket attacks. To cope with the massive psychological needs, a teacher-delivered protocol focusing on enhancing personal resilience was implemented. Children were assessed for risk factors, symptoms, and adaptation before the 16-week program (Time 1; n = 983) and after its completion (Time 2; n = 563). At a 3-month follow-up (Time 3; n = 754) children were assessed together with a waiting-list comparison group (n = 1,152). Participating children showed a significant symptom decrease at Time 2 and significantly fewer symptoms than the control group at Time 3. Six or more risk factors were associated with greater symptoms and parental concern about the child's adaptive functioning. Teachers are valuable cost-effective providers for clinically informed interventions after mass trauma and disaster.

Altered affinity of the platelet vesicular monoamine transporter 2 to dihydrotetrabenazine in children with major depression.

Platelet vesicular monoamine transporter (VMAT2) binding characteristics were assessed, using high affinity dihydrotetrabenazine ([(3)H]TBZOH) binding, in 14 children with major depression (MDD) and 16 matched controls. All participants underwent a thorough diagnostic evaluation and the levels of depression and anxiety were measured. K (d) values were significantly lower in children with MDD versus controls (2.93 ± 0.84 vs. 3.63 ± 0.56 nM, respectively, t = 2.4, df = 18.4, p = 0.025). B (max) values did not differ significantly. This preliminary finding indicates a possible structural change in platelet VMAT2 in children with MDD.

Preventing children's posttraumatic stress after disaster with teacher-based intervention: a controlled study.

OBJECTIVE: The psychological outcomes that the exposure to mass trauma has on children have been amply documented in the past decades. The objective of this study is to describe the effects of a universal, teacher-based preventive intervention implemented with Israeli students before the rocket attacks that occurred during Operation Cast Lead, compared with a nonintervention but exposed control group. METHOD: The study sample consisted of 1,488 students studying in fourth and fifth grades in a city in southern Israel who were exposed to continuous rocket attacks during Operation Cast Lead. The intervention group included about half (53.5%) of the children who studied in six schools where the teacher-led intervention was implemented 3 months before the traumatic exposure. The control group (46.5% of the sample) included six schools matched by exposure in which the preventive intervention was not implemented. Children filled out the UCLA-PTSD Reaction Index and the Stress/Mood Scale 3 months after the end of the rocket attacks. RESULTS: The intervention group displayed significantly lower symptoms of posttrauma and stress/mood than the control group (p < .001). Control children had 57% more detected cases of postraumatic stress disorder (PTSD) than participant children. This difference was significantly more pronounced among boys (10.2% versus 4.4%) and less among girls (12.5% versus 10.1%). CONCLUSIONS: The teacher-based, resilience-focused intervention is a universal, cost-effective approach to enhance the preparedness of communities of children to mass trauma and to prevent the development of PTSD after exposure.

A trauma-like model of political extremism: psycho-political fault lines in Israel.

This study examines a trauma-like model of potentially violent political extremism among Jewish Israelis. We study the psychosocial characteristics of political extremists that may lie at the root of sociopolitical instability and assess personal (gender, stressful life events, Holocaust family background, and political activism) and psychological parameters (self- and political transcendence, perceived political threats, in/out-group identification ratio) that may predict readiness to engage in destructive political behavior. We examine the ideological zeal of various political groups, the relationship between the latter and perceived political threats, and the predictors of extreme political activism. Results showed that the extreme political poles displayed high level of ideological and morbid transcendence. Right extremists displayed higher perceived threats to physical existence and national identity. Left extremists scored highest on perceived moral integrity threat. Higher perceived threats to national identity and moral integrity, risk, and self-transcendence statistically explain morbid transcendence. When fear conjures up extremely skewed sociopolitical identifications across political boundaries, morbid transcendence may manifest itself in destructive political activity.