Navigate Your Health: A Case Study of Organisational Learnings from an Integrated Care Pilot for Children and Young People in Care.

INTRODUCTION: Three peak organisations in Queensland, Australia partnered with consumers and other health and social sector partners to co-design and pilot the first known integrated, health navigation model to improve outcomes for children and young people in care in Australia. DESCRIPTION: An Organisational Learning theoretical lens has been used to present a narrative case study of findings structured as key learnings from the Navigate Your Health pilot to inform quality improvement, scalability and program sustainability. A developmental evaluation was completed whereby semi-structured interviews, focus groups, surveys, chart reviews, database excerpts and economic modelling was completed alongside project documentation analyses to create an evaluation framework. DISCUSSION: Findings highlighted the agency partners' drive to foster a more integrated and person-centred approach to care. The pilot's aim of improving health outcomes for a vulnerable population were achieved through a co-designed process which provided additional insights regarding partnerships, improvement, scalability and sustainability. CONCLUSION: Inter-agency responses to system fragmentation provide significant organisational learning opportunities. System integration is achievable through strengthened partnerships that can be sustained beyond a pilot phase to improve health outcomes for vulnerable/priority populations.

Nanostructural deformation of high-stiffness spruce wood under tension.

Conifer wood is an exceptionally stiff and strong material when its cellulose microfibrils are well aligned. However, it is not well understood how the polymer components cellulose, hemicelluloses and lignin co-operate to resist tensile stress in wood. From X-ray scattering, neutron scattering and spectroscopic data, collected under tension and processed by novel methods, the ordered, disordered and hemicellulose-coated cellulose components comprising each microfibril were shown to stretch together and demonstrated concerted, viscous stress relaxation facilitated by water. Different cellulose microfibrils did not all stretch to the same degree. Attempts were made to distinguish between microfibrils showing large and small elongation but these domains were shown to be similar with respect to orientation, crystalline disorder, hydration and the presence of bound xylan. These observations are consistent with a major stress transfer process between microfibrils being shear at interfaces in direct, hydrogen-bonded contact, as demonstrated by small-angle neutron scattering. If stress were transmitted between microfibrils by bridging hemicelluloses these might have been expected to show divergent stretching and relaxation behaviour, which was not observed. However lignin and hemicellulosic glucomannans may contribute to stress transfer on a larger length scale between microfibril bundles (macrofibrils).

Changes in Stereotypical Behavior Following Chlorpromazine Termination: Polypharmcy Effects on Response Class Membership.

OBJECTIVES: A paucity of information exists relating to the possible biological and environmental interactions influencing the occurrence of stereotypical behavior. In particular, there is limited research on the effects of psychotropic medication use on stereotypy presentation in individuals diagnosed with developmental disabilities such as intellectual disability and autism spectrum disorder. METHODS: We studied the stereotypy of a man with autism spectrum disorder and intellectual disability across 2 years. The topographies of stereotypical behavior included walking in circles, head tapping, arm flinging, and object stereotypy. These behaviors were observed weekly while the participant received daily dosages of 25 mg of chlorpromazine, 1.5 mg of lorazepam, and 2,500 mg of divalproex. At Week 75, chlorpromazine was discontinued while the other drugs and dosages were maintained. RESULTS: We observed a statistically significant decrease in walking in circles, but no changes in the other topographies of stereotypy. CONCLUSIONS: The results suggest that the gross motor activity was differentially affected by the chlorpromazine discontinuation and also suggests that alterations in dopamine receptor binding may have selectively influenced changes in stereotypical responding.

Functional analysis and intervention of perseverative speech in students with high-functioning autism and related neurodevelopmental disabilities.

Although perseverative speech is a common characteristic of individuals with high-functioning neurodevelopmental disabilities, little is known about the operant functions of these verbalizations. We conducted analogue functional analyses of perseverative speech for 2 students using reinforcement contingencies that included alone, attention, control, escape, and tangible conditions. Results showed the following patterns: attention only (Charlotte) or multiply determined including an attention function (Paul). We then tested an intervention for perseverative speech maintained by social positive reinforcement that included differential reinforcement of alternative behavior and extinction of perseverative speech for 1 participant. The intervention reduced perseverative speech, but did not increase appropriate speech until we added a prompting component. We then replicated this three-component intervention with Paul. The results showed moderate to high decreases in levels of perseverative speech and increased appropriate verbalizations in both cases. The results systematically replicated the interventions of previous studies by adding a prompting component to the intervention.

Assessment and treatment of challenging behaviour for individuals with intellectual disability: a research review.

BACKGROUND: Challenging behaviour is frequently associated with the presence of intellectual disability. If not effectively treated, chronic challenging behaviour can negatively impact a variety of quality of life outcomes for individuals with intellectual disability. METHODS AND RESULTS: We review the current status of research relating to the assessment and treatment of challenging behaviour for people with intellectual disability. We briefly review the history of interventions for challenging behaviour that led to the development of function-based approaches widely in use today. We then discuss the various operant functions of challenging behaviour, functional behaviour assessment technologies and reinforcement-based interventions. CONCLUSIONS: We conclude with a discussion of future directions that include models of prevention, ecological validity of assessment procedures and the widespread use of comprehensive behavioural support programmes.

Quantifying contingent relations from direct observation data: transitional probability comparisons versus Yule's Q.

Measuring contingencies or sequential associations may be applied to a broad range of response-stimulus, stimulus-stimulus, or response-response relations. Within behavior analysis, response-stimulus contingencies have been quantified by comparing 2 transitional probabilities and plotting them in contingency space. Within and outside behavior analysis, Yule's Q has become a recommended statistic used to quantify sequential associations between 2 events. In the current paper, we identify 2 methods of transitional probability comparisons used in the behavior-analytic literature to estimate contingencies in natural settings. We compare each of these methods to the more established Yule's Q statistic and evaluate relations between each pair of indices. Advantages and disadvantages of each method are identified, with recommendations as to which approach may be most appropriate for measuring contingencies.

Serotonin2A/C receptors mediate the aggressive phenotype of TLX gene knockout mice.

Deleting the tailless (TLX) gene in mice produces a highly aggressive phenotype yet to be characterized in terms of heterozygous animals or neurotransmitter mechanisms. We sought to establish pharmacological control over aggression and study the role of serotonin (5-HT)(2A/C) receptors in mediating changes in aggression. We analyzed aggression in mice heterozygous (+/-) or homozygous (-/-) for the TLX gene and wild-types (+/+) using a resident-intruder paradigm. No +/+ mice were aggressive, 36% of +/- TLX and 100% of -/- TLX mice showed aggression. Dose-effect functions were established for clozapine (0.1-1.5mg/kg, ip), ketanserin (0.3-1.25 mg/kg, ip), and (±)-1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane [(±)DOI] (0.5-2.0 mg/kg, ip). Injecting clozapine decreased the frequency and duration of attacks for +/- TLX and -/- TLX mice. Clozapine did not decrease grooming in either +/- TLX or -/- TLX mice but may have increased locomotion for -/- TLX mice. Injecting ketanserin, a 5-HT(2A/C) receptor antagonist, produced differential decreases in frequency and latency to aggression between genotypes and corresponding increases in locomotor behavior. Injecting (±)DOI, a 5-HT(2A/C) receptor agonist, increased the frequency and duration of attacks, decreased the latency to attacks, and decreased locomotion in +/- and -/- TLX mice. Results of the current study suggest aggression displayed by TLX null and heterozygous mice involves 5-HT(2A/C) receptors.

Towards the prevention of behavioural and psychiatric disorders in people with intellectual disabilities.

Intervention for behavioural and psychiatric disorders in people with intellectual disabilities often only takes place once these conditions are well established and more resistant to change. As an alternative, this paper promotes a public health prevention model and maps out opportunities for intervention at primary, secondary and tertiary levels. The resulting model is partly derived from generic research into these issues and partly on specific evidence on interventions for people with intellectual disabilities; it also contains more theoretical considerations. The additional research that is necessary to demonstrate the efficacy of the interventions identified is also considered. Central to this proposal is a greater integration of issues for people with intellectual disabilities within much broader policy and research agendas.

Structure of cellulose microfibrils in primary cell walls from collenchyma.

In the primary walls of growing plant cells, the glucose polymer cellulose is assembled into long microfibrils a few nanometers in diameter. The rigidity and orientation of these microfibrils control cell expansion; therefore, cellulose synthesis is a key factor in the growth and morphogenesis of plants. Celery (Apium graveolens) collenchyma is a useful model system for the study of primary wall microfibril structure because its microfibrils are oriented with unusual uniformity, facilitating spectroscopic and diffraction experiments. Using a combination of x-ray and neutron scattering methods with vibrational and nuclear magnetic resonance spectroscopy, we show that celery collenchyma microfibrils were 2.9 to 3.0 nm in mean diameter, with a most probable structure containing 24 chains in cross section, arranged in eight hydrogen-bonded sheets of three chains, with extensive disorder in lateral packing, conformation, and hydrogen bonding. A similar 18-chain structure, and 24-chain structures of different shape, fitted the data less well. Conformational disorder was largely restricted to the surface chains, but disorder in chain packing was not. That is, in position and orientation, the surface chains conformed to the disordered lattice constituting the core of each microfibril. There was evidence that adjacent microfibrils were noncovalently aggregated together over part of their length, suggesting that the need to disrupt these aggregates might be a constraining factor in growth and in the hydrolysis of cellulose for biofuel production.

Functional analysis of inappropriate social interactions in students with Asperger's syndrome.

We analyzed the inappropriate social interactions of 3 students with Asperger's syndrome whose behavior was maintained by social positive reinforcement. We tested whether inappropriate social behavior was sensitive to social positive reinforcement contingencies and whether such contingencies could be reversed to increase the probability of socially appropriate responding. Our results show that social positive reinforcers can be identified for inappropriate social interactions and that appropriate social behaviors can be sensitive to reinforcement contingency reversals.

Nanostructure of cellulose microfibrils in spruce wood.

The structure of cellulose microfibrils in wood is not known in detail, despite the abundance of cellulose in woody biomass and its importance for biology, energy, and engineering. The structure of the microfibrils of spruce wood cellulose was investigated using a range of spectroscopic methods coupled to small-angle neutron and wide-angle X-ray scattering. The scattering data were consistent with 24-chain microfibrils and favored a "rectangular" model with both hydrophobic and hydrophilic surfaces exposed. Disorder in chain packing and hydrogen bonding was shown to increase outwards from the microfibril center. The extent of disorder blurred the distinction between the I alpha and I beta allomorphs. Chains at the surface were distinct in conformation, with high levels of conformational disorder at C-6, less intramolecular hydrogen bonding and more outward-directed hydrogen bonding. Axial disorder could be explained in terms of twisting of the microfibrils, with implications for their biosynthesis.

Parametric analysis of thermal preference following sleep deprivation in the rat.

A thermal preference task was used to assess the effects of sleep deprivation on nociceptive behavior using hot and cool stimuli. The thermal preference apparatus allowed male rats to move freely from a hot thermal plate (44.7°C) to an adjacent plate at neutral (33.5°C) or cold temperatures (1.3-11°C). Investigators recorded occupancy on the colder side, frequency of movements between the 2 compartments, and first escape latency from the cold side. Parametric analysis of thermal preference indicated that behavioral allocation was related to temperature ranges previously associated with activation of thermal nociceptors. A 50% occupancy rate was determined from a stimulus-response function identifying 1.3°C vs. 44.7°C as optimal temperatures. This temperature combination was then used to test the effects of sleep deprivation for 48h using the pedestal-over-water method on response allocation to the 2 temperature zones. Sleep deprivation decreased time spent on the cooled plate. Cumulative occupancy indicated differential effects for sleep deprivation with the rats preferring to remain on the hot side vs. the cold side, suggesting that sleep deprivation increased the nociceptive properties of the cold stimulus.

Abolishing and establishing operation analyses of social attention as positive reinforcement for problem behavior.

Three participants whose problem behavior was maintained by contingent attention were exposed to 45-min presessions in which attention was withheld, provided on a fixed-time (FT) 15-s schedule, or provided on an FT 120-s schedule. Following each presession, participants were then tested in a 15-min session similar to the social attention condition of an analogue functional analysis. The results showed establishing operation conditions increased problem behavior during tests and that abolishing operation conditions decreased problem behavior during tests.

Association between serotonin transporter polymorphisms and problem behavior in adult males with intellectual disabilities.

Research on aggression over the past two decades has focused on gene-environment interaction models to explain the relative contribution of each to this behavioral phenotype in various clinical populations. Recent investigations suggest a link between aggression in people with intellectual disabilities the functionality of the serotonin transporter. The aims in this study were to examine the possible association of the STin2 and/or the 5-HTTLPR serotonin transporter polymorphisms in adult males with and without intellectual disabilities, and to examine the association of these polymorphisms with aggression in people with intellectual disabilities. DNA samples and behavioral records were obtained from adult males with intellectual disabilities, distinguished only by the presence or absence of aggression. No association was found between either transporter polymorphism for aggression. However, the long 5-HTTLPR allele, and not the short allele or the heterozygous state, was associated with the severity of aggression. The association with aggression appears to be genetically complex, suggesting there may be other genes, interactions between genes, and/or environmental relations occasioning aggression in people with intellectual disabilities.

Health and problem behavior among people with intellectual disabilities.

Good health significantly improves a person's quality of life. However, people with intellectual disabilities disproportionately have more health problems than the general population. Further complicating the matter is that people with more severe disabilities often cannot verbalize health complications they are experiencing, which leads to health problems being undiagnosed and untreated. It is plausible these conditions can interact with reinforcement contingencies to maintain problem behavior because of the increased incidence of health problems among people with intellectual disabilities. This paper reviews common health problems influencing problem behavior and reinforcement processes. A clear implication of this review is the need for comprehensive functional assessments of problem behavior involving behavior analysts and health professionals.

The Queensland Mental Health Clinical Collaborative and the management of schizophrenia.

OBJECTIVE: This paper describes the development of a collaborative group of mental health clinicians who have come together to improve practice in adult acute mental health settings for the inpatient management of schizophrenia. METHOD: Sixteen acute adult mental health inpatient services across Queensland worked together to develop clinical indicators related to the inpatient treatment of schizophrenia. Data collection was conducted by using information available on existing databases and through statewide chart audits using scannable form technology. Through a secure intranet site, and statewide forums, clinicians were able to access information on clinical indicators enabling them to compare their site data to peer and state data. RESULTS: Available data from 15 of the 16 sites provided information on clinical indicators including average length of stay, 28-day readmission rates, antipsychotic prescribing, medication dose and the use of multiple antipsychotic medications at discharge. CONCLUSIONS: The formation of the Mental Health Clinical Collaborative has brought together clinicians across the State to develop clinical indicators and openly discuss ideas to inform and improve clinical practice. This process has been effective in improving the quality of routinely collected information across the State and in engaging clinicians in using health information to drive clinical practice.