Rapid assessment of cognitive function in down syndrome across intellectual level and dementia status.

BACKGROUND: Adults with Down syndrome (DS) are at risk of developing dementia and cognitive assessment is a fundamental part of the diagnostic process. Previously, we developed a Rapid Assessment for Developmental Disabilities (RADD), a brief, broadly focused direct test of cognition. In the current report, we assess whether the RADD is sensitive to dementia in DS and the degree to which it compares with other cognitive measures of dementia in this population. METHODS: In a sample of 114 individuals with DS, with dementia diagnosed in 62%, the RADD was compared with the Dementia Questionnaire for Mentally Retarded Persons (DMR), the Bristol Activities of Daily Living Scale, Severe Impairment Battery (SIB), and the Brief Praxis Test (BPT). RESULTS: The RADD showed predicted effects across intellectual disability (ID) levels and dementia status (p < 0.001). Six-month test-retest reliability for the subset of individuals without dementia was high (r(41) = 0.95, p < 0.001). Criterion-referenced validity was demonstrated by correlations between RADD scores and ID levels based upon prior intelligence testing and clinical diagnoses (rs (114) = 0.67, p = 0.001) and with other measures of cognitive skills, such as the BPT, SIB, and DMR-Sum of Cognitive scores (range 0.84 through 0.92). Using receiver operating characteristic curves for groups varying in pre-morbid severity of ID, the RADD exhibited high sensitivity (0.87) and specificity (0.81) in discriminating among individuals with and without dementia, although sensitivity was somewhat lower (0.73) for the subsample of dementia cases diagnosed no more than 2 years prior to their RADD assessment. CONCLUSION: Taken together, findings indicated that the RADD, a relatively brief, easy-to-administer test for cognitive function assessment across ID levels and dementia status, would be a useful component of cognitive assessments for adults with DS, including assessments explicitly focused on dementia.

ERCP and stent therapy for progressive jaundice in hepatocellular carcinoma: which patients benefit, which patients don't?

Jaundice in hepatocellular carcinoma (HCC) can be due to biliary obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) can be both diagnostic and therapeutic. Biliary stenting can relieve jaundice and allow further chemotherapy, but at additional expense and potential morbidity. We sought to determine whether CT scan or ultrasound (US) could identify which patients with HCC and jaundice would benefit from endoscopic stenting. We retrospectively analyzed 26 patients with HCC and jaundice who underwent ERCP after CT or US. We compared biliary dilation on CT or US with the dominant biliary stricture seen on ERCP, and with response to biliary stenting. Eleven of 26 patients had dominant biliary stricture on ERCP; 11 underwent stenting. Six of 11 (55%) stented patients had a significant decline in bilirubin; three became eligible for further chemotherapy. All six responders to stenting had biliary dilation on prior CT or US. Procedure-related complications occurred in 1/11 (9%) who underwent stent placement. In conclusion, in selected patients, stenting can safely relieve jaundice and allow subsequent chemotherapy. CT or US accurately predicted lesions that responded to stenting. ERCP and stenting provided no benefit in the absence of biliary dilation on CT or US.

A critical review of pharmacotherapy for youth with anxiety disorders: things are not as they seem.

Given the increasing trend in clinical child psychology and psychiatry toward cost-effective and pharmacological treatment, a review of key factors that influence treatment outcomes in this area seems warranted. This is especially important for the rapidly changing area of childhood anxiety disorders. In this article, we look at different change producing procedures to illustrate the claim that pharmacological studies are not necessarily what they seem. Specifically, pharmacological outcome studies are classified and reviewed on the basis of varying "secondary" treatments described in method sections. Three groups and efficacy rates were determined: (a) pharmacotherapy only (42.83%), (b) pharmacotherapy plus general/supportive psychotherapy (27.74%), and (c) pharmacotherapy plus a behavior therapy component (65.28%). We also discuss the implications of these findings for research as well as other methodological and theoretical concerns regarding the reviewed articles. These concerns include (a) methods used to diagnose participants, (b) methods used to assess improvement, (c) emphasis on diagnostic categories, (d) exclusionary criteria and comorbidity, (e) participant attrition and follow-up, and (f) key developmental and social contextual variables.

Diagnostic criteria for the neuropathological assessment of Alzheimer's disease: current status and major issues.

A Consensus Conference focusing on Alzheimer's disease (AD) took place in November 1996 to recommend uniform evaluation procedures and diagnostic criteria, co-sponsored by the National Institute on Aging and the Reagan Institute of the Alzheimer's Association. In conjunction with this conference, we reviewed diagnostic practices in current use, together with various neuropathological criteria proposed since 1985. Difficulties were identified in developing "gold standard" criteria for diagnosis and case classification of AD based upon the current state of knowledge. Working criteria for use within research contexts were proposed that acknowledged the realities of scientific limitations by inclusion of a broad and heterogeneous category of "uncertain" cases. (Eventually, methods will be developed for identifying these cases as preclinical AD, dementia due to multiple causes or non-AD, but this is not now possible.) Within applied contexts, the use of CERAD guidelines was supported. Finally, recommendations generated at the Consensus Conference were discussed, emphasizing the rapid pace of recent scientific advancement and the need for ongoing empirical reevaluation and modification of the Group's proposal.

A preliminary analysis of a functional model of assessment and treatment for school refusal behavior.

We assessed whether treatment of children and adolescents with school refusal behavior is effective when based upon an individualized, functional analysis. Seven children and adolescents, who were currently experiencing difficulties attending school, were evaluated with the School Refusal Assessment Scale (SRAS), an instrument designed to identify maintaining variables surrounding school refusal behavior. These included specific fearfulness/general overanxiousness, escape from aversive social situations, attention-getting or separation anxious behavior, and tangible reinforcement. Prescriptive treatment was given in accordance with the assessed motivating condition and included systematic desensitization/relaxation training, modeling and cognitive restructuring, shaping and differential reinforcement of other behavior, and contingency contracting for each condition, respectively. Daily measures of anxiety, depression, distress, and school attendance were taken, as well as pretreatment, posttreatment, and 6-month follow-up child and/or parent questionnaires. Results indicated that 6 of the subjects maintained full-time school attendance by posttreatment and at the 6-month follow-up. All reported moderate improvements in daily levels of anxiety, depression, and/or distress. The implications of a prescriptive treatment approach for school refusal behavior are discussed.

A state-wide assessment of training needs of community mental health administrators.

In order to construct a trainee-designed continuing education (CE) program for administrators, a training needs assessment of all community mental health agencies in Illinois was conducted using a framework of pertinent organization, task, and individual variables. Mental health administrators were, indeed, interested in CE. Areas of interest included leadership, clinical services, planning and evaluation, supplemental services, accountability and accreditation. Funding source was the key variable in relation to training priorities. However, other variables such as comprehensiveness, caseload, serving all ages, and years of experience were also related to training interests. There were contrasts in organization, task, and administrator variables but not in training preferences in relation to geographic location. Implications of administrator/agency descriptive data for the planning of CE are discussed.

A statewide assessment of mental health governing board training needs.

This paper describes a statewide survey assessment of the training needs of governing board members and presents a demographic profile of governing board presidents. Presidents of the 55 governing boards in a consortium of state-funded, community-based mental health agencies were mailed questionnaires. They were asked to respond in terms of board rather than individual priorities. Forty-four questionnaires were returned representing 80% of the sample and 57% of all governing boards in the state. Seventy-one percent of the respondents were male and 55% were executives or managers. Their mean age was 45. Of the 10 needs assessment items, the two highest rated pertained to the financing of centers and knowledge of mental health legislation. Three areas of need emerged from a factor analysis: a board mandate factor, a board organization factor, and a planning and evaluation factor. The perceived training needs of the Chicago Metropolitan Area and Downstate Illinois were similar. The issue of effective citizen involvement vis-à-vis valid representation and appropriate training was discussed.

Primary presenting problem and mental health service delivery.

This study describes the variety of problems reported by clients seeking the services of a large urban community mental health center and explores the extent to which these problems are related to three sets of variables: client demographic characteristics, system entry, and system response. A 10% random sample totaling 273 case files was examined. The most frequently reported problem area was interpersonal followed by drug/alcohol abuse and cognitive disturbance. Clients' presenting problem was significantly related to all three sets of variables. Implications for planning service delivery are discussed with emphasis on identifying both unique and shared center responses to presenting problems, client characteristics, and system entry factors.

Knowledge assessment of mental health advisory boards.

Informed citizen advisory boards are vital to the operation of community mental health programs. In order to provide relevant educational experiences, a continuing education program conducted a survey of the self-judged level of knowledge of a sample of board members in a large city. The sample consisted of 57 respondents representing 16 of 19 city mental health centers and the three federally funded community health centers located in the city. The results indicated areas of strength and weakness. Also, knowledge assessments differeed in relation to years of experience on advisory boards. Several suggestions are made about designing curricula for mental advisory boards.

Day hospital in the context of a community mental health program.

The paper focuses on the role of the day hospital within the framework of total care delivery in community mental health programs and stresses its unique position in the continuity of care cycle. The day hospital lies midway in the service continuum between inpatient and outpatient services and can provide a bridge between community and intramural resources. As such it can serve as a "center for change' where inputs from the entire network of services merge to test solutions for care delivery problems. Experiences with a specific day are used to illustrate relevant issues for those currently engaged in planning or implementing day hospital services.