A mixed-method study exploring barriers and facilitators to midwives' mental health in Ontario.

BACKGROUND: There is a paucity of information regarding the mental health of midwives working in Ontario, Canada. Many studies have investigated midwives' mental health around the world, but little is known about how the model of midwifery care in Ontario contributes to or negatively impacts midwives' mental health. The aim of the study was to gain a deeper understanding of factors that contribute to and negatively impact Ontario midwives' mental health. METHODS: We employed a mixed-methods, sequential, exploratory design, which utilized focus groups and individual interviews, followed by an online survey. All midwives in Ontario who had actively practiced within the previous 15 months were eligible to participate. FINDINGS: We conducted 6 focus groups and 3 individual interviews, with 24 midwives, and 275 midwives subsequently completed the online survey. We identified four broad factors that impacted midwives' mental health: (1) the nature of midwifery work, (2) the remuneration model, (3) the culture of the profession, and (4) external factors. DISCUSSION: Based on our findings and the existing literature, we have five broad recommendations for improving Ontario midwives' mental health: (1) provide a variety of work options for midwives; (2) address the impacts of trauma on midwives; (3) make mental health services tailored for midwives accessible; (4) support healthy midwife-to-midwife relationships; and (5) support improved respect and understanding of midwifery. CONCLUSION: As one of the first comprehensive investigations into midwives' mental health in Ontario, this study highlights factors that contribute negatively to midwives' mental health and offers recommendations for how midwives' mental health can be improved systemically.

Lyme borreliosis in pregnancy and associations with parent and offspring health outcomes: An international cross-sectional survey.

Background: Lyme disease (LD) is a complex tick-borne pathology caused by Borrelia burgdorferi sensu lato bacteria. Currently, there are limited data regarding the health outcomes of people infected during pregnancy, the potential for perinatal transmission to their fetus, and the long-term effects on these children. Therefore, the primary objective of this survey study was to investigate the impact of LD in pregnancy on both the parent and their offspring. Methods: A seven-section survey was developed and administered in REDCap. Although recruitment was primarily through LD-focused organizations, participation was open to anyone over the age of 18 who had been pregnant. Participant health/symptoms were compared across those with "Diagnosed LD," "Suspected LD," or "No LD" at any time in their lives. The timing of LD events in the participants' histories (tick bite, diagnosis, treatment start, etc.) were then utilized to classify the participants' pregnancies into one of five groups: "Probable Treated LD," "Probable Untreated LD," "Possible Untreated LD," "No Evidence of LD," and "Unclear." Results: A total of 691 eligible people participated in the survey, of whom 65% had Diagnosed LD, 6% had Suspected LD, and 29% had No LD ever. Both the Diagnosed LD and Suspected LD groups indicated a high symptom burden (p < 0.01). Unfortunately, direct testing of fetal/newborn tissues for Borrelia burgdorferi only occurred following 3% of pregnancies at risk of transmission; positive/equivocal results were obtained in 14% of these cases. Pregnancies with No Evidence of LD experienced the fewest complications (p < 0.01) and were most likely to result in a live birth (p = 0.01) and limited short- and long-term offspring pathologies (p < 0.01). Within the LD-affected pregnancy groups, obtaining treatment did not decrease complications for the parent themselves but did ameliorate neonatal health status, with reduced rates of rashes, hypotonia, and respiratory distress (all p < 0.01). The impact of parent LD treatment on longer-term child outcomes was less clear. Conclusion: Overall, this pioneering survey represents significant progress toward understanding the effects of LD on pregnancy and child health. A large prospective study of pregnant people with LD, combining consistent diagnostic testing, exhaustive assessment of fetal/newborn samples, and long-term offspring follow-up, is warranted.

Cognition, ADHD Symptoms, and Functional Impairment in Children and Adolescents With Neurofibromatosis Type 1.

Objective: We examined the contribution of attention and executive cognitive processes to ADHD symptomatology in NF1, as well as the relationships between cognition and ADHD symptoms with functional outcomes. Methods: The study sample consisted of 141 children and adolescents with NF1. Children were administered neuropsychological tests that assessed attention and executive function, from which latent cognitive variables were derived. ADHD symptomatology, adaptive skills, and quality of life (QoL) were assessed using parent-rated questionnaires. Path analyses were conducted to test relationships among cognitive functioning, ADHD symptomatology, and functional outcomes. Results: Significant deficits were observed on all outcome variables. Cognitive variables did not predict ADHD symptomatology. Neither did they predict functional outcomes. However, elevated ADHD symptomatology significantly predicted functional outcomes. Conclusion: Irrespective of cognitive deficits, elevated ADHD symptoms in children with NF1 negatively impact daily functioning and emphasize the importance of interventions aimed at minimizing ADHD symptoms in NF1.

Knowledge of US Midwifery Credentials Among Members of the American College of Nurse-Midwives.

INTRODUCTION: Three midwifery credentials are granted in the United States: certified nurse-midwife (CNM), certified midwife (CM), and certified professional midwife (CPM). Confusion about US midwifery credentials may restrict growth of the midwifery profession. This survey assessed American College of Nurse-Midwives (ACNM) members' knowledge of US midwifery credentials. METHODS: ACNM members (N = 7551) were surveyed via email in 2017. The survey asked respondents to report demographic information and to identify correct statements about the education, certification, and scope of practice of CNMs, CMs, and CPMs. Responses to 17 items about all midwives certified in the United States, a 5-item subset specific to CNMs/CMs, and one item related to location of midwifery practice by credential were analyzed. RESULTS: Nearly a quarter of the membership (22.1%) responded to the survey. Higher scores on the survey indicated greater identification of correct statements about the education, certification, scope, and location of practice of CNMs, CMs, and CPMs. Significant differences in scores were found among ACNM members based on their level of education, degree of professional involvement in midwifery, and prior practice as a nurse. ACNM members with higher scores on the survey held a doctorate, worked in Region I, and had greater professional leadership involvement in midwifery organizations. Participants with less nursing experience prior to their midwifery education also scored significantly higher on the survey. DISCUSSION: Although two-thirds of respondents correctly answered items on the preparation, credentialing, and scope of practice of CNMs, CMs, and CPMs, a significant minority had gaps in knowledge. Results of this survey suggest the need for outreach about US midwifery credentials. Future research to replicate and expand upon this survey may benefit the profession of midwifery in the United States.

Dlx5 and Dlx6 can antagonize cell division at the G1/S checkpoint.

BACKGROUND: Dlx5 and Dlx6 stimulate differentiation of diverse progenitors during embryonic development. Their actions as pro-differentiation transcription factors includes the up-regulation of differentiation markers but the extent to which differentiation may also be stimulated by regulation of the cell cycle has not been addressed. RESULTS: We document that expression of Dlx5 and Dlx6 antagonizes cell proliferation in a variety of cell types without inducing apoptosis or promoting cell cycle exit. Rather, a variety of evidence indicates that elevated Dlx5 and Dlx6 expression reduces the proportion of cells in S phase and affects the length of the cell cycle. CONCLUSIONS: Antagonism of S-phase entry by Dlx5 and Dlx6 proteins likely represents a lineage-independent function to effect Dlx-mediated differentiation in multiple progenitor cell types.

Exploring the Potential of Participatory Theatre to Reduce Stigma and Promote Health Equity for Lesbian, Gay, Bisexual, and Transgender (LGBT) People in Swaziland and Lesotho.

Stigma and discrimination affecting lesbian, gay, bisexual, and transgender (LGBT) people compromise health and human rights and exacerbate the HIV epidemic. Scant research has explored effective LGBT stigma reduction strategies in low- and middle-income countries. We developed and pilot-tested a participatory theatre intervention (PTI) to reduce LGBT stigma in Swaziland and Lesotho, countries with the world's highest HIV prevalence. We collected preliminary data from in-depth interviews with LGBT people in Lesotho and Swaziland to enhance understanding of LGBT stigma. Local LGBT and theatre groups worked with these data to create a 2-hour PTI composed of three skits on LGBT stigma in health care, family, and community settings in Swaziland (Manzini) and Lesotho (Maseru, Mapoteng). Participants ( n = 106; nursing students, health care providers, educators, community members) completed 12 focus groups following the PTI. We conducted thematic analysis to understand reactions to the PTI. Focus groups revealed the PTI increased understanding of LGBT persons and issues, increased empathy, and fostered self-reflection of personal biases. Increased understanding included enhanced awareness of the negative impacts of LGBT stigma, and of LGBT people's lived experiences and issues. Participants discussed changes in attitude and perspective through self-reflection and learning. The format of the theatre performance was described as conducive to learning and preferred over more conventional educational methods. Findings indicate changed attitudes and awareness toward LGBT persons and issues following a PTI in Swaziland and Lesotho. Stigma reduction interventions may help mitigate barriers to HIV prevention, treatment, and care in these settings with a high burden of HIV.

Opportunities and challenges for evidence-informed HIV-noncommunicable disease integrated care policies and programs: lessons from Malawi, South Africa, Swaziland and Kenya.

INTRODUCTION: Countries in sub-Saharan Africa (SSA) are recognizing the growing dual burden of HIV and noncommunicable diseases (NCDs). This article explores the availability, implementation processes, opportunities and challenges for policies and programs for HIV/NCD integration in four SSA countries: Malawi, Kenya, South Africa and Swaziland. METHODS: We conducted a cross-sectional analysis of current policies and programs relating to HIV/NCD care integration from January to April 2017 using document review and expert opinions. The review focussed on availability and content of relevant policy documents and processes towards implementating national HIV/NCD integration policies. RESULTS: All four case study countries had at least one policy document including aspects of HIV/NCD care integration. Apart from South Africa that had a phased nation-wide implementation of a comprehensive integrated chronic disease model, the three other countries - Malawi, Kenya and Swaziland, had either pilot implementations or nation-wide single-disease integration of NCDs and HIV. Opportunities for HIV/NCD integration policies included: presence of overarching health policy documents that recognize the need for integration, and coordinated action by policymakers, researchers and implementers. Evidence gaps for cost-effectiveness, effects of integration on key HIV and NCD outcomes and funding mechanisms for sustained implementation of integrated HIV/NCD care strategies, were among challenges identified. CONCLUSION: Policymakers in Malawi, Kenya, South Africa and Swaziland have considered integration of NCD and HIV care but a lack of robust evidence hampers large-scale implementation of HIV/NCD integration. It is crucial for SSA Ministries of Health and throughout low-and-middle-income countries to utilize existing opportunities and advocate for evidence-informed HIV/NCD integration strategies.

Missed opportunities: Do states require screening of children for health conditions that interfere with learning?

METHODS: Investigators reviewed websites of state departments of health and education, and legislation for all 50 states and DC. For states with mandated screenings and a required form, investigators applied structured analysis to assess HBL inclusion. RESULTS: No state mandated that schools require screening for all 7 HBLs. Less than half (49%) required comprehensive school health examinations and only 12 states plus DC required a specific form. Of these, 12 of the forms required documentation of vision screening, 11 of hearing screening, and 12 of dental screening. Ten forms asked about asthma and 9 required documentation of lead testing. Seven asked about general well-being, emotional problems, or mental health. None addressed hunger. When including states without comprehensive school health examination requirements, the most commonly required HBL screenings were for vision (80% of states; includes DC), hearing (75% of states; includes DC) and dental (24% of state; includes DC). CONCLUSION: The lack of state mandated requirements for regular student health screening represents a missed opportunity to identify children with HBLs. Without state mandates, accompanying comprehensive forms, and protocols, children continue to be at risk of untreated health conditions that can undermine their success in school.

The Reliability and Predictive Validity of the Stalking Risk Profile.

This study assessed the reliability and validity of the Stalking Risk Profile (SRP), a structured measure for assessing stalking risks. The SRP was administered at the point of assessment or retrospectively from file review for 241 adult stalkers (91% male) referred to a community-based forensic mental health service. Interrater reliability was high for stalker type, and moderate-to-substantial for risk judgments and domain scores. Evidence for predictive validity and discrimination between stalking recidivists and nonrecidivists for risk judgments depended on follow-up duration. Discrimination was moderate (area under the curve = 0.66-0.68) and positive and negative predictive values good over the full follow-up period ( Mdn = 170.43 weeks). At 6 months, discrimination was better than chance only for judgments related to stalking of new victims (area under the curve = 0.75); however, high-risk stalkers still reoffended against their original victim(s) 2 to 4 times as often as low-risk stalkers. Implications for the clinical utility and refinement of the SRP are discussed.

Greater retention in care among adolescents on antiretroviral treatment accessing "Teen Club" an adolescent-centred differentiated care model compared with standard of care: a nested case-control study at a tertiary referral hospital in Malawi.

INTRODUCTION: There are numerous barriers to the care and support of adolescents living with HIV (ALHIV) that makes this population particularly vulnerable to attrition from care, poor adherence and virological failure. In 2010, a Teen Club was established in Zomba Central Hospital (ZCH), Malawi, a tertiary referral HIV clinic. Teen Club provides ALHIV on antiretroviral treatment (ART) with dedicated clinic time, sexual and reproductive health education, peer mentorship, ART refill and support for positive living and treatment adherence. The purpose of this study was to evaluate whether attending Teen Club improves retention in ART care. METHODS: We conducted a nested case-control study with stratified selection, using programmatic data from 2004 to 2015. Cases (ALHIV not retained in care) and controls (ALHIV retained in care) were matched by ART initiation age group. Patient records were reviewed retrospectively and subjects were followed starting in March 2010, the month in which Teen Club was opened. Follow-up ended at the time patients were no longer considered retained in care or on 31 December 2015. Cases and controls were drawn from a study population of 617 ALHIV. Of those, 302 (48.9%) participated in at least two Teen Club sessions. From the study population, 135 (non-retained) cases and 405 (retained) controls were selected. RESULTS: In multivariable analyses, Teen Club exposure, age at the time of selection and year of ART initiation were independently associated with attrition. ALHIV with no Teen Club exposure were less likely to be retained than those with Teen Club exposure (adjusted odds ratio (aOR) 0.27; 95% CI 0.16, 0.45) when adjusted for sex, ART initiation age, current age, reason for ART initiation and year of ART initiation. ALHIV in the age group 15 to 19 were more likely to have attrition from care than ALHIV in the age group 10 to 14 years of age (aOR 2.14; 95% CI 1.12, 4.11). CONCLUSIONS: This study contributes to the limited evidence evaluating the effectiveness of service delivery interventions to support ALHIV within healthcare settings. Prospective evaluation of the Teen Club package with higher methodological quality is required for programmes and governments in low- and middle-income settings to prioritize interventions for ALHIV and determine their cost-effectiveness.

Assessment of autoantibodies to interferon-ω in patients with autoimmune polyendocrine syndrome type 1: using a new immunoprecipitation assay.

BACKGROUND: Measurements of autoantibodies to interferon-ω (IFN-ω) in patients with autoimmune polyglandular syndrome type 1 (APS-1) were performed using a new immunoprecipitation assay (IPA) based on 125I-labeled IFN-ω. METHODS: We have developed and validated a new IPA based on 125I-labeled IFN-ω. Sera from 78 patients (aged 3-78 years) with clinically diagnosed APS-1, 35 first degree relatives, 323 patients with other adrenal or non-adrenal autoimmune diseases and 84 healthy blood donors were used in the study. In addition, clinical features and autoimmune regulator (AIRE) genotype for the APS-1 patients were analyzed. RESULTS: Sixty-six (84.6%) of 78 APS-1 patients were positive for IFN-ω Ab using 125I-labeled IFN-ω IPA. IFN-ω Ab was the most prevalent of the six different autoantibodies tested in this group of APS-1 patients. All 66 IFN-ω Ab-positive APS-1 patients had AIRE mutations and 7 IFN-ω Ab-negative patients had no detectable AIRE mutations, whereas 3 (3.8%) patients were discrepant for IFN-ω Ab positivity and AIRE mutation results. Out of autoimmune controls studied, two patients were positive for IFN-ω Ab. Positivity and levels of IFN-ω Ab in the APS-1 patients studied were similar irrespective of patient's clinical phenotype and AIRE genotype. Furthermore, IFN-ω Ab levels did not change over time (up to 36 years of disease duration) in 8 APS-1 patients studied. CONCLUSIONS: We have developed a novel, highly sensitive and specific assay for measurement of IFN-ω Ab. It provides a simple and convenient method for the assessment of patients with APS-1 and selecting patients suspected of having APS-1 for AIRE gene analysis.

Minority Stress and Safer Sex Practices Among Sexual Minority Women in Toronto, Canada: Results from a Cross-Sectional Internet-Based Survey.

PURPOSE: Sexual stigma is a chronic stressor that enhances vulnerability to mental health disparities among lesbian, gay, bisexual, and queer people. Sexual stigma has also been associated with reduced uptake of safer sex practices, such as condom use, among gay and bisexual men. Scant research has examined the relationship between sexual stigma and safer sex practices among sexual minority women (SMW), including lesbian, bisexual, and queer women. METHODS: We explored associations between sexual stigma and safer sex practices among SMW. We also tested the interaction between sexual stigma, social support, and resilient coping in this relationship. A cross-sectional internet-based survey was administered to SMW in Toronto, Canada. RESULTS: Among 388 participants with complete measurement data, simple linear regression indicated both perceived and enacted sexual stigma were positively associated with uptake of safer sex practices. In multivariable analyses, significant interactions were found between perceived sexual stigma and resilient coping, and between enacted sexual stigma and social support. At low levels of resilient coping, higher levels of perceived sexual stigma were associated with fewer safer sex practices, while at high levels of resilient coping the relationship was reversed. At low levels of social support, higher levels of enacted sexual stigma were associated with fewer safer sex practices, while at high levels of social support the relationship was reversed. CONCLUSIONS: These findings document complex relationships between sexual stigma dimensions, coping, social support, and safer sex practices. Understanding the role these variables play in uptake of safer sex practices can inform sexual health interventions tailored for SMW.

Measuring inputs to a common function: The case of Dlx5 and Dlx6.

Physically linked Dlx5 and Dlx6 paralogs are co-expressed in vertebrates and various combinations of null alleles in mice demonstrate not only functional redundancy between the paralogous factors but a similar quantitative contribution to craniofacial functions during development. While it is not possible to rule out that the bigene pair contributes some paralog-specific functions it is clear that, for many functions in the head, Dlx5 and Dlx6 are interchangeable. To assess the relative quantitative contribution made by each paralog to bigene function, we have made comparisons of the expression of Dlx5 and Dlx6 in chick embryos and quantitated the transcriptional properties of the encoded proteins in a variety of regulatory and cellular contexts. Our data indicate that the transcriptional activities of both Dlx5 and Dlx6 are very much context dependent; isolated domains fused to a heterologous DNA binding domain have little intrinsic activity, while individual domains are more active when contiguous with their own homeodomain. We find Dlx5 and Dlx6 to be quantitatively indistinguishable on a variety of natural cis-regulatory sequences in a heterologous cellular context but observed quantitatively different transcriptional outputs in cells that normally express these genes, suggesting differential interactions with co-evolved co-activators.

Management and treatment of stalkers: problems, options, and solutions.

Legal sanctions alone are often ineffective in preventing stalking because, in the absence of treatment, the fundamental problems driving the stalker remain unresolved. Criminal justice interventions can be problematic because of difficulties in framing anti-stalking legislation and inconsistencies in their application. Civil remedies in the form of restraining orders may be ineffective or counterproductive. Treatment of stalkers involves pharmacotherapy when mental illness is present, but the mainstays of treatment for non-psychotic stalkers are programmes of psychological intervention. These depend on accurate assessment of the risks inherent in stalking and on the identification of psychological deficits, needs, and responsivity factors specific to the individual. Treatment can then be tailored to suit the stalker, thereby enhancing therapeutic efficacy. Developing a framework for identifying the risk factors and shaping the delivery of treatment is crucial. Two service innovations developed specifically to work with stalkers are presented as options to overcome current management deficiencies.

The effects of social desirability response bias on STAXI-2 profiles in a clinical forensic sample.

OBJECTIVES: This study investigated the proposition that the 'State-trait anger expression inventory' (2nd ed.; STAXI-2) is susceptible to impression management (IM) and Self-Deceptive Enhancement (SDE) in clinical forensic populations. It was hypothesized that individuals engaging in IM would report significantly lower levels of trait anger, external expression of anger, and internal expression of anger on the STAXI-2. Those reporting above average SDE were predicted to claim higher levels of anger control. DESIGN: A between-groups design was used, comparing STAXI-2 scores of individuals who reported high levels of IM and SDE to those who did not. METHOD: One-hundred and fifty-nine male patients of a community forensic mental health service, referred for assessment of stalking behaviours, completed the STAXI-2 and Paulhus Deception Scales (PDS). Individuals engaging in high levels of IM and SDE were compared to low scorers in regard to STAXI-2 scales using Mann-Whitney U tests. RESULTS: Individuals engaging in IM had significantly lower levels of reported trait anger, outward expression of anger, and inward expression of anger, and higher levels of anger control. Similar results were found with the SDE scale, although the magnitude of the effect was smaller and not apparent on all subscales. CONCLUSIONS: The STAXI-2 was vulnerable to social desirability response bias in this sample of forensic clients. Where the STAXI-2 is used as a basis for treatment recommendations and decisions, it should be administered and interpreted in conjunction with a recognized measure of such bias to improve validity.

A study of the predictors of persistence in stalking situations.

Stalkers engaging in persistent campaigns of harassment have the potential to cause immense harm to their victims and themselves. Being able to estimate which stalkers are likely to persist longest is important to clinicians dealing with both perpetrators and victims. This study of 200 stalkers investigated characteristics of the stalkers and their behaviour that were associated with increased persistence. Logistic regression models were developed to predict low, moderate, and highly persistent stalking. The results supported previous research indicating that the type of prior relationship between stalker and victim is strongly associated with persistence, with prior acquaintances the most persistent, and strangers least. Being aged over 30, sending the victim unsolicited materials, and having an intimacy seeking or resentful motivation was also associated with greater persistence, as was the presence of psychosis.

Parental bonding and adult attachment styles in different types of stalker.

Attachment theory is one of the earliest and most vigorously promoted explanations of the psychological processes that underlie stalking behavior. Insecure attachment has been proposed as impairing the management of relationships, thus increasing the propensity to stalk. The current study explored the parental bonding and adult attachment styles of 122 stalkers referred to a specialist forensic clinic. Stalkers were grouped according to two common classification methods: relationship and motivation. Compared to general community samples, stalkers were more likely to remember their parents as emotionally neglectful and have insecure adult attachment styles, with the degree of divergence varying according to stalker type and mode of classification. In offering support for the theoretical proposition that stalking evolves from pathological attachment, these findings highlight the need to consider attachment in the assessment and management of stalkers. Also emphasized is the importance of taking classification methods into account when interpreting and evaluating stalking research.

Assessing and managing the risks in the stalking situation.

Stalking is a common social problem, often driven by psychiatric disorder in its perpetrators and productive of psychological and social damage in its victims. Assessing and managing the risks in the stalking situation is a task that frequently falls on the mental health professional. The concerns of risks in the stalking situation are not confined to violence but include psychosocial damage, chronicity, and recurrence, and, for the stalker, arrest and incarceration. This article outlines a structured approach to assessment and management involving domains based on the relationship between stalker and victim, the type of motivation driving the stalking, the stalker's risk profile, the victim's risk profile, and finally, the legal and mental health context. The assessment is closely linked to management strategies to counter specific ascertained risks and future hazards. These strategies will be limited, or facilitated, according to the current legal and mental health contexts that have a critical impact on the stalking situation.

Exploring connectivity of the brain's white matter with dynamic queries.

Diffusion Tensor Imaging (DTI) is a magnetic resonance imaging method that can be used to measure local information about the structure of white matter within the human brain. Combining DTI data with the computational methods of MR tractography, neuroscientists can estimate the locations and sizes of nerve bundles (white matter pathways) that course through the human brain. Neuroscientists have used visualization techniques to better understand tractography data, but they often struggle with the abundance and complexity of the pathways. In this paper, we describe a novel set of interaction techniques that make it easier to explore and interpret such pathways. Specifically, our application allows neuroscientists to place and interactively manipulate box or ellipsoid-shaped regions to selectively display pathways that pass through specific anatomical areas. These regions can be used in coordination with a simple and flexible query language which allows for arbitrary combinations of these queries using Boolean logic operators. A representation of the cortical surface is provided for specifying queries of pathways that may be relevant to gray matter structures and for displaying activation information obtained from functional magnetic resonance imaging. By precomputing the pathways and their statistical properties, we obtain the speed necessary for interactive question-and-answer sessions with brain researchers. We survey some questions that researchers have been asking about tractography data and show how our system can be used to answer these questions efficiently.

The problem behavior model: the development of a stalkers clinic and a threateners clinic.

Traditionally, forensic mental health services have focused on the assessment and treatment of offenders with serious mental disorders. In recent years, there has been growing recognition that forensic clinicians have an important role to play for those offenders who engage in criminal acts driven by psychological or/and social problems, which may, or may not, occur in conjunction with a major mental disorder. This is especially true for specific offenses such as stalking and threatening. This article describes the innovation of the problem behavior model. This model uses a reductionist approach and the nexus between psychiatry and psychology to address the complex phenomena associated with specific problem behaviors that often culminate in offenses. The model is illustrated by describing the development of specialist clinics for the problem behaviors of stalking and threatening.