Approach to autism spectrum disorder: Using the new DSM-V diagnostic criteria and the CanMEDS-FM framework.

OBJECTIVE: To review the diagnostic criteria for autism spectrum disorder (ASD) from the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), and to develop an approach to managing ASD using the CanMEDS- Family Medicine (CanMEDS-FM) framework. SOURCES OF INFORMATION: The DSM-V from the American Psychiatric Association, published in May 2013, provides new diagnostic criteria for ASD. The College of Family Physicians of Canada's CanMEDS-FM framework provides a blueprint that can guide the complex management of ASD. We used data from the Centers for Disease Control and Prevention to determine the prevalence of ASD, and we used the comprehensive systematic review and meta-analysis completed by the UK National Institute for Health and Care Excellence for their guidelines on ASD to assess the evidence for more than 100 interventions. MAIN MESSAGE: The prevalence of ASD was 1 in 88 in 2008 in the United States according to data from the Centers for Disease Control and Prevention. The ASD classification in the fourth edition of the DSM included autism, Asperger syndrome, pervasive developmental disorder, and childhood disintegrative disorder. The new DSM-V revision incorporates all these disorders into one ASD umbrella term with different severity levels. The management of ASD is complex and requires a multidisciplinary team effort and continuity of care. The CanMEDS-FM roles provide a framework for management. CONCLUSION: Family physicians are the key leaders of the multidisciplinary care team for ASD, and the CanMEDS-FM framework provides a comprehensive guide to help manage a child with ASD and to help the child's family.

Assessment of consultation impact on emergency department operations through novel metrics of responsiveness and decision-making efficiency.

OBJECTIVES: Requests for specialty consultation are common in emergency departments (EDs) and often contribute to delays in throughput. Our objectives were to describe the contribution of the consultation process to total ED length of stay (LOS) through novel metrics and illustrate causes of delay. METHODS: We conducted a prospective cross-sectional study at three Canadian tertiary care centres. Adult ED patients with requested medical/surgical consultations were enrolled. We created original metric intervals: total consultation time (TCT) defined as the interval from the initial consultation request to the disposition decision, consult response time (CRT) from the request to the consultant arrival, and decision-making interval (DMI) from arrival to the disposition decision. The consultation impact index (CII) was defined as the percentage of ED LOS consumed by the TCT. Reasons for delay were documented if time stamps exceeded preset benchmarks. RESULTS: The median TCT for 285 patients was 138 minutes (interquartile range [IQR]: 82-239 minutes), whereas the median total ED LOS was 778 minutes (IQR 485-1,274 minutes). The median CRT was 55 minutes (IQR 21-115 minutes), and the median DMI was 58 minutes (IQR 25-126 minutes). The CII measured 26% (95% CI 23-28). Major contributors to consultation delay included urgent ward issues, simultaneous ED consultations, and the need for additional laboratory or radiographic investigations. CONCLUSION: The consultation process is highly variable and has an important impact on ED LOS. We describe novel measures related to consultation performance and provide an analysis of what causes delays. These results can be used to seek improvements in the consulting process.

Development and validation of an instrument to assess perceived social influence on health behaviors.

Assessment of social influence on health behavior is often approached through a situational context. The current study adapted an existing, theory-based instrument from another content domain to assess Perceived Social Influence on Health Behavior (PSI-HB) among African Americans, using an individual difference approach. The adapted instrument was found to have high internal reliability (α = .81-.84) and acceptable test-retest reliability (r = .68-.85). A measurement model revealed a three-factor structure and supported the theoretical underpinnings. Scores were predictive of health behaviors, particularly among women. Future research using the new instrument may have applied value assessing social influence in the context of health interventions.

Development and Validation of Instruments to Assess Potential Religion-Health Mechanisms in an African American Population.

The health disparities that negatively affect African Americans are well-documented; however, there are also many sociocultural factors that may play a protective role in health outcomes. Religious involvement is noted to be important in the African American community and to have a positive association with health outcomes. However, few studies have explained why this relationship exists. This article reports on the development and validation of instruments to assess two proposed mediators of the relationship between religiosity and health for an African American population; perceived religious influence on health behaviors and illness as punishment from a higher power. We used a systematic iterative process, including interviews and questionnaire data from African Americans who provided feedback on item wording. We also solicited input from African American pastors. In a sample of 55 African Americans, the instruments appeared to have strong internal reliability (alpha = .74 and .91, respectively) as well as test-retest reliability (r = .65, .84, respectively, p < .001). Evidence far construct validity is also discussed, as are recommendations for health disparities research using these instruments.

Messages from moms: barriers to and facilitators of behavior change in a lead poisoning preventive education project.

Qualitative focus group data from participants of an intensive, culture-specific, lead poisoning preventive education research project were analyzed to assess success of communication strategies, and, specifically, to identify barriers to and facilitators of adopting behavior changes encouraged in the project. Effectiveness of education in preventing lead poisoning is addressed elsewhere. Education focused on housecleaning, hygiene, water, and nutrition. Ninety-five participants (89% of 107 eligible) of six ethnicities agreed to participate in focus groups. Seventy-eight (82%) actually attended. Barriers to behavior change included the effort required or unpleasantness of a prevention strategy, presentation of familiar information, denial of the problem, busyness, perceived lack of control, lack of social support, cultural traditions, and misunderstandings. Requiring one-time behavior changes; teaching simple, easy strategies; making less appealing tasks fun; demonstrating concepts; and presenting novel material that piques interest were features of the education that facilitated behavior change. Factors internal to the participant, such as love of the child or cultural practices, also served to motivate the participant to change behavior or to facilitate adoption of a prevention strategy. We offer recommendations to assist others in designing effective health education and risk communication prevention or intervention programs.

Validation of rat reference genes for improved quantitative gene expression analysis using low density arrays.

Real-time PCR has become increasingly important in gene expression profiling research, and it is widely agreed that normalized data are required for accurate estimates of messenger RNA (mRNA) expression. With increased gene expression profiling in preclinical research and toxicogenomics, a need for reference genes in the rat has emerged, and the studies in this area have not yet been thoroughly evaluated. The purpose of our study was to evaluate a panel of rat reference genes for variation of gene expression in different tissue types. We selected 48 known target genes based on their putative invariability. The gene expression of all targets was examined in 11 types of rat tissues using TaqMan low density array (LDA) technology. The variability of each gene was assessed using a two-step statistical model. The analysis of mean expression using multiple reference genes was shown to provide accurate and reliable normalized expression data. The least five variable genes from each specific tissue were recommended for future tissue-specific studies. Finally, a subset of investigated rat reference genes showing the least variation is recommended for further evaluation using the LDA platform. Our work should considerably enhance a researcher's ability to simply and efficiently identify appropriate reference genes for given experiments.

Adapting judicial supervision to the risk level of drug offenders: discharge and 6-month outcomes from a prospective matching study.

This article reports recent findings from a program of experimental research examining the effects of adapting judicial supervision to the risk level of drug-abusing offenders. Prior studies revealed that high-risk participants with (1) antisocial personality disorder or (2) a history of drug abuse treatment performed significantly better in drug court when they were scheduled to attend frequent, bi-weekly judicial status hearings in court. Low-risk participants performed equivalently regardless of the schedule of court hearings. The current study prospectively matched misdemeanor drug court clients to the optimal schedule of court hearings based upon an assessment of their risk status, and compared outcomes to those of clients randomly assigned to the standard schedule of court hearings. Results confirmed that high-risk participants graduated at a higher rate, provided more drug-negative urine specimens at 6 months post-admission, and reported significantly less drug use and alcohol intoxication at 6 months post-admission when they were matched to bi-weekly hearings as compared to the usual schedule of hearings. These findings yield practical information for enhancing the efficacy and cost-efficiency of drug court services. Directions for future research on adaptive programming for drug offenders are discussed.

Matching Judicial Supervision to Clients' Risk Status in Drug Court.

This article reports outcomes from a program of experimental research evaluating the risk principle in drug courts. Prior studies revealed that participants who were high risk and had (a) antisocial personality disorder or (b) a prior history of drug abuse treatment performed better in drug court when scheduled to attend biweekly judicial status hearings in court. In contrast, participants who were low risk performed equivalently regardless of the court hearings schedule. This study prospectively matches drug court clients to the optimal schedule of court hearings based on an assessment of their risk status and compares outcomes to clients randomly assigned to the standard hearings schedule. Results confirmed that participants who were high risk and matched to biweekly hearings had better during-treatment outcomes than participants assigned to status hearings as usual. These findings provide confirmation of the risk principle in drug courts and yield practical information for enhancing the efficacy and cost-efficiency of drug courts.

Are judicial status hearings a "key component" of drug court? Six and twelve months outcomes.

Substantial evidence indicates that drug courts can be superior to traditional probation programs for enhancing treatment retention and reducing substance use and crime among drug offenders. Few studies have isolated the effects of the hypothesized "key components" of drug courts to determine their contributions to outcomes. This article presents outcomes at 6 and 12 months post-admission for misdemeanor drug court clients who were randomly assigned to different dosages of judicial status hearings. Although earlier work revealed superior during-treatment effects for high-risk participants who were assigned to more frequent bi-weekly hearings, those effects did not extend post-treatment. The results did reveal significant pre-to-post improvements for participants, as a whole, in self-reported drug use, alcohol use, and criminal recidivism; however, lacking a no-drug court control condition, it is not possible to discern the magnitude of the effect of the drug court program. Approximately, half of the participants resumed drug or alcohol use within 12 months of admission to drug court, and approximately 10-15% resumed illegal activities. These findings lend credence to the potential effectiveness of drug courts; however, continuing-care strategies are required to extend the effects of drug courts beyond the initial active phases of the program.

Do research payments precipitate drug use or coerce participation?

Providing high-magnitude cash incentives to substance abuse clients to participate in research is frequently viewed as unethical based on the concerns that this might precipitate new drug use or be perceived as coercive. We randomly assigned consenting drug abuse outpatients to receive payments of 10 US dollars, 40 US dollars, or 70 US dollars in either cash or gift certificate for attending a 6-month research follow-up assessment. At the 6-month follow-up, participants received their randomly determined incentive and were then scheduled for a second follow-up appointment 3 days later to detect new instances of drug use. Findings indicated that neither the magnitude nor mode of the incentives had a significant effect on rates of new drug use or perceptions of coercion. Consistent with the contingency management literature, higher payments and cash payments were associated with increased follow-up rates. Finally, the results suggest that higher magnitude payments may be more cost-effective by reducing the need for more intensive follow-up efforts.

Perceived deterrence and outcomes in drug court.

According to perceived-deterrence theory, the likelihood that an offender will engage in drug use or illegal activity is influenced by the perceived certainty of being detected for infractions or recognized for accomplishments, the perceived certainty of receiving sanctions for infractions or rewards for accomplishments, and the anticipated magnitude of the sanctions and rewards. This study evaluated drug court participants' perceived deterrence at monthly intervals during their enrollment in drug court. Exploratory cluster analysis (N=255) on the longitudinal scores yielded five subtypes of drug offenders characterized either by consistently elevated perceived-deterrence scores, consistently moderate scores, consistently low scores, increasing scores, or decreasing scores. The best outcomes were associated with consistently elevated scores, whereas the worst outcomes were associated with scores that declined over time as the participants became accustomed to the program. The clusters also differed in predicted directions on demographic variables. The correlational design does not permit inferences of causality; however, the results lend credence to perceived deterrence as a potential explanatory mechanism for the effects of drug courts.

Recommendations from lead poisoning prevention program participants: best practices.

We present a program evaluation of the Phillips Lead Project, a 5-year study of the effectiveness of culture-specific, peer education in maintaining low blood lead levels of children in an inner-city neighborhood. We conducted focus groups to understand how project participants felt about the various strategies employed by the Lead Project. The purpose of this article is to describe their reactions to the project and make recommendations concerning appropriate educational strategies for lead poisoning prevention projects being undertaken in similar communities. Although this project was a research study, many of its methods, and participants' reactions to those methods, are relevant to non-research prevention programs and may be generalizable to other health issues besides lead poisoning.

Condom use among low-income African American males attending an STD clinic.

OBJECTIVE: To evaluate condom-use attitudes and behaviors among low-income, primarily African American, male patients seeking care at an urban sexually transmitted disease (STD) clinic. METHODS: Via face-to-face interviews, 224 males completed a theory-based questionnaire regarding condom use. RESULTS: The results show that although respondents had obvious signs and symptoms of infection and that 65% were "repeaters" at the clinic, 66% of the sample reporting a main partner and 33% of those with other types of sexual partners were not motivationally ready to use condoms consistently. CONCLUSION: Based on their STD clinic attendance, these men obviously perceive themselves at risk for STDs, but appear to cope with this risk by choosing to engage in secondary rather than primary preventive behaviors.

Status hearings in drug court: when more is less and less is more.

We examined the effects of increasing the number of times misdemeanor drug court clients appeared before a judge for judicial status hearings. Our previous findings showed no main effect of increased hearings during the first 14 weeks of the program. The present study examined participants' discharge status in the program, and also explored potential interactions between client characteristics and the frequency of judicial status hearings on outcomes. Results revealed no main effects for hearing frequency on graduation status. Drug offenders who satisfied DSM-IV criteria for antisocial personality disorder (APD) achieved more weeks of urinalysis-confirmed drug abstinence when assigned to more frequent judicial status hearings, whereas subjects without APD achieved more abstinence and were more likely to graduate successfully from the program when assigned to less frequent hearings. Additionally, clients with a history of substance abuse treatment achieved more weeks of abstinence when assigned to more frequent hearings. These findings lend useful guidance to drug courts. Status hearings are expensive and time consuming and should be targeted to clients who would benefit most from them.