The current extent of and need for shared decision making in atopic dermatitis and psoriasis in the Netherlands: an online survey study amongst patients and physicians.

BACKGROUND: In shared decision making (SDM), patients and physicians work together to choose the best treatment option for an individual patient. Atopic dermatitis (AD) and psoriasis are particularly suitable for SDM, considering that the best treatment option depends on a patient's preferences and values (preference-sensitive decisions). Currently, it is unknown to what extent SDM is applied in treatment decisions for these diseases in the Netherlands. OBJECTIVES: Primary, to assess the current extent of SDM in AD and psoriasis in the Netherlands amongst patients and dermatologists. Secondary, to assess the degree to which patients and physicians endorse SDM, to explore which characteristics are related to their preference to be involved in SDM and to identify which barriers and facilitators for SDM they perceive. METHODS: Two similar online surveys, one for patients with AD or psoriasis and one for (resident) dermatologists, were carried out. The surveys comprised validated questionnaires (shared decision making questionnaire (SDM-Q; range 0-100), Control Preference Scale) and study-specific statements mainly regarding barriers and facilitators for SDM. RESULTS: The responses of 219 patients and 147 physicians were analysed. Dermatologists experienced significantly more SDM than patients (SDM-Q 82 vs 55; P < 0.01). Most patients and dermatologists prefer to share treatment decisions. Mainly facilitators for SDM were perceived, including the positive perception of patients and dermatologists regarding SDM. The perceived barriers included lack of continuity of care by the same physician and lack of time. CONCLUSION: Despite the dermatologists' optimistic perspective, patients experience a limited extent of SDM and physicians should be aware of this gap. Improvement of SDM in AD and psoriasis is needed. The positive attitude of patients and dermatologists towards the process and outcome of SDM is important facilitators, while barriers were mainly perceived on an organizational level.

Prospective study of home morphine infusion in 62 terminally ill patients.

The project "Infusion Therapy at Home" studied the practice of parenteral infusion therapy at home. Among the treatment modalities was the administration of morphine infusions to terminally ill patients. With infusion of morphine, patients were pain-free on 73% of the treatment days. Quality of care, quality of life, and costs were acceptable.

Time-delay discrimination training with impulsive children: self-monitoring nonwait responses and the dimensions of prompts.

This study investigated whether in time-delay discrimination training, the performance of impulsive children can be improved by requiring self-monitoring of the correctness of nonwait responses, and to what extent these improvements are a function of the dimensions of the prompts. Four experiments, in each of which multiple prompts were used, one for each stimulus (S+, S-), were done. Comparisons between time delay of distinctive- and nondistinctive-feature prompts, with and without self-monitoring, were made across and within subjects. Time delay of distinctive-feature prompts without self-monitoring did not produce learning. The added requirement of self-monitoring nonwait responses led to a dramatic improvement in performance, but only when distinctive-feature cues were used for prompting and self-monitoring.

Derived relational responding as generalized operant behavior.

The major aim of the present study was to demonstrate that derived relational responding may be viewed as a form of generalized operant behavior. In Experiment 1, 4 subjects were divided into two conditions (2 in each condition). Using a two-comparison matching-to-sample procedure, all subjects were trained and tested for the formation of two combinatorially entailed relations. Subjects were trained and tested across multiple stimulus sets. Each set was composed of novel stimuli. Both Conditions 1 and 2 involved explicit performance-contingent feedback presented at the end of each block of test trials (i.e., delayed feedback). In Condition 1, feedback was accurate (consistent with the experimenter-designated relations) following exposure to the initial stimulus sets. When subjects' responding reached a predefined mastery criterion, the feedback then switched to inaccurate (not consistent with the experimenter-designated relations) until responding once again reached a predefined criterion. Condition 2 was similar to Condition 1, except that exposure to the initial stimulus sets was followed by inaccurate feedback and once the criterion was reached feedback switched to accurate. Once relational responding emerged and stabilized, response patterns on novel stimulus sets were controlled by the feedback delivered for previous stimulus sets. Experiment 2 replicated Experiment 1, except that during Conditions 3 and 4 four comparison stimuli were employed during training and testing. Experiment 3 was similar to Condition 1 of Experiment 1, except that after the mastery criterion was reached for class-consistent responding, feedback alternated from accurate to inaccurate across each successive stimulus set. Experiment 4 involved two types of feedback, one type following tests for mutual entailment and the other type following tests for combinatorial entailment. Results from this experiment demonstrated that mutual and combinatorial entailment may be controlled independently by accurate and inaccurate feedback. Overall, the data support the suggestion, made by relational frame theory, that derived relational responding is a form of generalized operant behavior.

A precursor to the relational evaluation procedure: searching for the contextual cues that control equivalence responding.

The precursor to the relational evaluation procedure (pREP) is a go/no-go successive discrimination procedure for examining stimulus equivalence. Previous research has shown that it does not readily produce equivalence responding unless some matching-to-sample (MTS) procedures are incorporated into the experimental sequence. Two experiments attempted to identify contextual cues that would generate equivalence responding on the pREP. Experiment 1 examined the effects of using abstract symbols or various verbal labels as response options on the pREP. Only the words same and different, when used as response options, reliably produced equivalence responding across 4 subjects. Experiment 2 examined different pretraining preparations designed to attach the functions of the words same and different to abstract symbols that could then be used as response options on the pREP. The most effective pretraining procedure involved multiple-exemplar training during which subjects were trained to respond to abstract symbols in the presence of pairs of stimuli that were either formally the same or different. The abstract symbols were subsequently used as response options with the pREP, and all subjects reliably demonstrated equivalence responding. The findings suggest that the relations of same and different may be fundamental to equivalence responding. These findings are discussed in terms of what they suggest about the nature of the equivalence phenomenon specifically and derived relational responding more generally.

Hearing assessment in developmentally impaired infants: classical conditioning as a supplement to brainstem-evoked response audiometry (BERA).

The brainstem-evoked response audiometry (BERA) is probably the most common approach to hearing assessment in high-risk and developmentally handicapped infants. It is usually suggested, however, that BERA should not be the sole assessment method. In an attempt to determine an effective supplement to BERA, the present study evaluated a classical conditioning procedure with developmentally impaired babies. Within this procedure, different tones served as conditioned stimuli while an air-puff was used as the unconditioned stimulus. Results indicate that this procedure could be successfully applied with almost all of the babies.

Self-stimulation and task-related responding: the role of sensory reinforcement in maintaining and extending treatment effects.

The present study was aimed at (a) eliminating self-stimulation and increasing task-related responding in severely handicapped children, and (b) assessing maintenance and carry-over of treatment effects following the use of sensory reinforcement. The results showed that applying sensory or edible-liquid reinforcement, contingent on low rates of task-related responses, did not increase these responses nor decrease self-stimulation. These behavior changes were obtained with the combination of reinforcement and punishment. Sensory reinforcement was effective in maintaining and extending the treatment results, while edible-liquid contingencies were not.

Time-delay discrimination training: replication with different stimuli and different populations.

Two time-delay conditions for teaching complex visual discriminations to normal preschoolers and children with mild and moderate intellectual handicaps were compared. One condition involved spatially separating the distinctive components from the redundant parts of both stimuli (multiple dynamic distinctive-feature prompts). The other condition involved adding a colored field to the correct stimulus (single static nondistinctive-feature prompt). The effect of the latter condition was assessed with unlearned and learned tasks. The study consisted of four experiments. In one experiment, children were also required to use the prompts for self-monitoring responses given before prompting had occurred. The results indicated that for all populations and stimuli (a) time delay of multiple dynamic distinctive-feature prompts consistently produced learning, and (b) time delay of the single static nondistinctive-feature prompt almost never produced learning and frequently led to a complete loss of discriminative performance on previously learned tasks. The resistance to disruption was a function of the training history (i.e., with or without time delay) and IQ level. Self-monitoring increased the efficacy of time delay when multiple dynamic distinctive-feature prompts were used but not when the single static nondistinctive-feature prompt was used.

Stimulus manipulation versus delayed feedback for teaching missing minuend problems to difficult-to-teach students.

The present study evaluated two procedures, Stimulus Manipulation and Delay Feedback Only, for teaching difficult-to-teach students to solve missing minuend problems (i.e., missing number problems starting with a minus sign). The Stimulus Manipulation procedure was directed at establishing the target skill with a minimum of errors. The training consisted of three phases of several steps each. The first phase was designed to establish a nonnumerical response to a prompt, the shape of which was gradually transformed into the final discriminative stimulus. The second phase was designed to extend the control of this stimulus to the numerical operations and to eliminate all supplementary stimuli. The third phase gradually eliminated the originally trained nonnumerical responses. The Delayed Feedback Only procedure included no stimulus manipulation and consisted of the experimenter giving only delayed right.wrong feedback on the solutions. The data indicate that both procedures resulted in all (N = 4) subjects (a) learning to solve the target problems, (b) generalizing this skill to similar, more advanced problems, and (c) maintaining it over multiple intervals of several consecutive weeks. However, systematic differences in error rate and long-term retention across training methods were observed, favoring the Stimulus Manipulation procedure.

Introducing EMR children to arithmetical operations: a program involving pictorial problems and distinctive-feature prompts.

This study assessed a program involving distinctive-feature prompts for teaching four EMR children to use the appropriate arithmetical operations (addition, subtraction, multiplication, and division) in the presence of multicomponent pictorial problems. The prompts highlighted critical features of the problems and cued the operations implied. The operations were computed by means of pocket calculators adapted to the response requirements. Training was carried out according to a modified multiple-probe design. Data indicate that the program was effective in establishing the use of operations with all subjects. This behavior was also displayed on problems portraying actions not included in training. The findings are discussed in terms of distinctive-feature prompting, orienting responses, and self-cueing. Attention is given to the generalization of responding across problems, and to educational implications of the program.

Establishing sound blending in moderately mentally retarded children: implications of verbal instruction and pictorial prompting.

The present study evaluated a program for establishing blending of consonants (C) and vowel-consonant (VC) syllables in moderately mentally retarded children. The study consisted of two experiments. Experiment 1 assessed whether the subjects' failure to blend was due to the task requirements per se, or to the inadequacy of the instructional terminology ("Say together"). Experiment 2 evaluated the implications of using pictorial prompts in the acquisition and generalization of C-VC blending. The data revealed that (a) adequate verbal instruction had a modest but significant effect on the subjects' blending performance (Experiment 1), and (b) training without pictorial prompts resulted in better blending of trained and untrained C-VC items than training with pictorial prompts (Experiment 2).

Teaching moderately mentally retarded children basic reading skills.

The present study assessed the efficacy of a program for teaching moderately mentally retarded children basic reading skills. Central to the program were the use of a phonemic alphabet as well as the application of pictorial cueing and stimulus manipulation techniques. The program consisted of six phases. It started with the training of graphemes for vowels (Phase 1) and ended with the training of two-syllable words (Phase 6). Four moderately mentally retarded students participated. Given time constraints, not all subjects completed all phases of the program. The training ended with the reading of one-syllable three letter words for one subject, one-syllable four letter words for two subjects, and two-syllable words for one subject. Subsequent generalization tests revealed that all subjects were capable of reading untrained words of the same complexity as those previously trained; and to read and, to a lesser extent, understand simple sentences. The execution of the program required an average training time of 35 hours per subject. Aspects pertaining to the validity of the program, the efficacy of the procedures, and the relevance of the learned skills are discussed.

Teaching toothbrushing behavior in severely retarded adults: systematic reduction of feedback and duration training.

Eight severely retarded adults were trained to brush their teeth. Component behaviours were trained in a predetermined sequence of 15 steps. Training included scheduled opportunities for independence performance, instruction, modelling and partial and total physical guidance. Four types of feedback were used, i.e., verbal praise plus explicit head nodding, explicit nodding, inconspicous nodding and no feedback. Stepwise reduction of feedback was made contingent on a subject's repeated performance of each individual step. Five of the eight subjects learned to perform all 15 steps for three consecutive sessions. A different procedure for fading out feedback was used for the other three subjects, two of which learned to perform 14 steps reliably. Acquisition training was followed by procedures to establish persistance of criterion performances for an interval of eight days. Training procedures were based on interval shaping. All seven subjects learned to demonstrate the 14 or 15 component behaviours after an interval of eight to 17 days in which no systematic training occured.

The effects of different reinforcement conditions on the test performance of multihandicapped deaf children.

The present study explored the effects of different reinforcement conditions on the number of correct responses on the Rvaen Progressive Matrices. Four groups of 11- to 18-year-old multihandicapped deaf children matched on the basis of mean age and pretest scores were used. The groups were randomly assigned to any of four posttest conditions: end-of-session reinforcement, noncontingent reinforcement, delayed reinforcement, and immediate reinforcement. The mean posttest score of subjects tested under the immediate-reinforcement condition was significantly higher than that of any other group. No significant differences were observed between the mean posttest scores of the three other groups. The practical implications of using reinforcement procedures for testing purposes are discussed.

Shaping self-initiated toileting in infants.

We evaluated a method for training infants to cue their mothers on the need to eliminate. The program consisted of three phases: Phase I was directed at establishing a close temporal relationship between body signals (straining) and subsequent defecations on the potty; Phase II was designed to establish a relationship between prompted and unprompted potty reaching/grabbing responses and eliminations (defecations and urinations) on the potty; and Phase III served to establish unprompted potty reaching/grabbing responses as reliable precursors of eliminations. Four babies, between 3.1 and 6.6 months old, all completed the training before age 1 year, with no negative side effects.

A scalogram analysis of behavioral strategies in severely and profoundly retarded adults.

The present study was designed to provide empirical evidence for an assumed order sequence of five behavioral strategies in 75 severely and profoundly retarded adults. A behavioral strategy was defined as a set of task-related behaviors each of which is controlled by the same stimulus properties of the materials. Four sets of tasks were used to measure four of the five strategies. Multiple presentation modes were employed to enhance the Ss' understanding of the demand characteristics of the tasks. A scalogram analysis revealed that the four sets of items met the requirements for a cumulative scale. Additional analyses were performed to identify individual items measuring a specific behavioral strategy. The obtained results indicated that most items measured one strategy although not always the one for which they were designed. The additional value of the described classification system over other, more traditional measures, is discussed.