Supporting the nation's transitioning veterans: Narrative review of practices and recommendations for psychotherapy and counseling of veterans separating from military service.

Each year, approximately 200,000 service members transition out of military service and return to civilian life. For many, the stresses of this military-to-civilian transition are vast and include instabilities in mental health, relationships, employment, education, and housing. Given their unique training, mental health professionals often find themselves on the front lines of efforts to support this population. However, to date, literature to guide work with this population has been scant and disorganized. This narrative review provides practitioners both within and outside the Veterans Health Administration with an overview of relevant literature in this area and offers concrete, practical recommendations for how to best support transitioning Veterans through psychotherapy and counseling. Three major themes are reviewed: (a) Engagement strategies, including clinical style, mitigation of privacy concerns, and consideration of broader psychosocial issues; (b) contextual considerations, including challenges of the "Thank You for Your Service" phenomenon, identity considerations, and circumstances of discharge; and (c) information about available services. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Parent-mediated interventions for promoting communication and language development in young children with Down syndrome.

BACKGROUND: Communication and language development are areas of particular weakness for young children with Down syndrome. Caregivers' interaction with children influences language development, so many early interventions involve training parents how best to respond to their children and provide appropriate language stimulation. Thus, these interventions are mediated through parents, who in turn are trained and coached in the implementation of interventions by clinicians. As the interventions involve a considerable commitment from clinicians and families, we undertook this review to synthesise the evidence of their effectiveness. OBJECTIVES: To assess the effects of parent-mediated interventions for improving communication and language development in young children with Down syndrome. Other outcomes are parental behaviour and responsivity, parental stress and satisfaction, and children's non-verbal means of communicating, socialisation and behaviour. SEARCH METHODS: In January 2018 we searched CENTRAL, MEDLINE, Embase and 14 other databases. We also searched three trials registers, checked the reference lists of relevant reports identified by the electronic searches, searched the websites of professional organizations, and contacted their staff and other researchers working in the field to identify other relevant published, unpublished and ongoing studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs that compared parent-mediated interventions designed to improve communication and language versus teaching/treatment as usual (TAU) or no treatment or delayed (wait-listed) treatment, in children with Down syndrome aged between birth and six years. We included studies delivering the parent-mediated intervention in conjunction with a clinician-mediated intervention, as long as the intervention group was the only group to receive the former and both groups received the latter. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures for data collection and analysis. MAIN RESULTS: We included three studies involving 45 children aged between 29 months and six years with Down syndrome. Two studies compared parent-mediated interventions versus TAU; the third compared a parent-mediated plus clinician-mediated intervention versus a clinician-mediated intervention alone. Treatment duration varied from 12 weeks to six months. One study provided nine group sessions and four individualised home-based sessions over a 13-week period. Another study provided weekly, individual clinic-based or home-based sessions lasting 1.5 to 2 hours, over a six-month period. The third study provided one 2- to 3-hour group session followed by bi-weekly, individual clinic-based sessions plus once-weekly home-based sessions for 12 weeks. Because of the different study designs and outcome measures used, we were unable to conduct a meta-analysis.We judged all three studies to be at high risk of bias in relation to blinding of participants (not possible due to the nature of the intervention) and blinding of outcome assessors, and at an unclear risk of bias for allocation concealment. We judged one study to be at unclear risk of selection bias, as authors did not report the methods used to generate the random sequence; at high risk of reporting bias, as they did not report on one assessed outcome; and at high risk of detection bias, as the control group had a cointervention and only parents in the intervention group were made aware of the target words for their children. The sample sizes of each included study were very small, meaning that they are unlikely to be representative of the target population.The findings from the three included studies were inconsistent. Two studies found no differences in expressive or receptive language abilities between the groups, whether measured by direct assessment or parent reports. However, they did find that children in the intervention group could use more targeted vocabulary items or utterances with language targets in certain contexts postintervention, compared to those in the control group; this was not maintained 12 months later. The third study found gains for the intervention group on total-language measures immediately postintervention.One study did not find any differences in parental stress scores between the groups at any time point up to 12 months postintervention. All three studies noted differences in most measures of how the parents talked to and interacted with their children postintervention, and in one study most strategies were maintained in the intervention group at 12 months postintervention. No study reported evidence of language attrition following the intervention in either group, while one study found positive outcomes on children's socialisation skills in the intervention group. One study looked at adherence to the treatment through attendance data, finding that mothers in the intervention group attended seven out of nine group sessions and were present for four home visits. No study measured parental use of the strategies outside of the intervention sessions.A grant from the Hospital for Sick Children Foundation (Toronto, Ontario, Canada) funded one study. Another received partial funding from the National Institute of Child Health and Human Development and the Department of Education in the USA. The remaining study did not specify any funding sources.In light of the serious limitations in methodology, and the small number of studies included, we considered the overall quality of the evidence, as assessed by GRADE, to be very low. This means that we have very little confidence in the results, and further research is very likely to have an important impact on our confidence in the estimate of treatment effect. AUTHORS' CONCLUSIONS: There is currently insufficient evidence to determine the effects of parent-mediated interventions for improving the language and communication of children with Down syndrome. We found only three small studies of very low quality. This review highlights the need for well-designed studies, including RCTs, to evaluate the effectiveness of parent-mediated interventions. Trials should use valid, reliable and similar measures of language development, and they should include measures of secondary outcomes more distal to the intervention, such as family well-being. Treatment fidelity, in particular parental dosage of the intervention outside of prescribed sessions, also needs to be documented.

Non-speech oral motor treatment for children with developmental speech sound disorders.

BACKGROUND: Children with developmental speech sound disorders have difficulties in producing the speech sounds of their native language. These speech difficulties could be due to structural, sensory or neurophysiological causes (e.g. hearing impairment), but more often the cause of the problem is unknown. One treatment approach used by speech-language therapists/pathologists is non-speech oral motor treatment (NSOMT). NSOMTs are non-speech activities that aim to stimulate or improve speech production and treat specific speech errors. For example, using exercises such as smiling, pursing, blowing into horns, blowing bubbles, and lip massage to target lip mobility for the production of speech sounds involving the lips, such as /p/, /b/, and /m/. The efficacy of this treatment approach is controversial, and evidence regarding the efficacy of NSOMTs needs to be examined. OBJECTIVES: To assess the efficacy of non-speech oral motor treatment (NSOMT) in treating children with developmental speech sound disorders who have speech errors. SEARCH METHODS: In April 2014 we searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (R) and Ovid MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Education Resources Information Center (ERIC), PsycINFO and 11 other databases. We also searched five trial and research registers, checked the reference lists of relevant titles identified by the search and contacted researchers to identify other possible published and unpublished studies. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials that compared (1) NSOMT versus placebo or control; and (2) NSOMT as adjunctive treatment or speech intervention versus speech intervention alone, for children aged three to 16 years with developmental speech sound disorders, as judged by a speech and language therapist. Individuals with an intellectual disability (e.g. Down syndrome) or a physical disability were not excluded. DATA COLLECTION AND ANALYSIS: The Trials Search Co-ordinator of the Cochrane Developmental, Psychosocial and Learning Problems Group and one review author ran the searches. Two review authors independently screened titles and abstracts to eliminate irrelevant studies, extracted data from the included studies and assessed risk of bias in each of these studies. In cases of ambiguity or information missing from the paper, we contacted trial authors. MAIN RESULTS: This review identified three studies (from four reports) involving a total of 22 children that investigated the efficacy of NSOMT as adjunctive treatment to conventional speech intervention versus conventional speech intervention for children with speech sound disorders. One study, a randomised controlled trial (RCT), included four boys aged seven years one month to nine years six months - all had speech sound disorders, and two had additional conditions (one was diagnosed as "communication impaired" and the other as "multiply disabled"). Of the two quasi-randomised controlled trials, one included 10 children (six boys and four girls), aged five years eight months to six years nine months, with speech sound disorders as a result of tongue thrust, and the other study included eight children (four boys and four girls), aged three to six years, with moderate to severe articulation disorder only. Two studies did not find NSOMT as adjunctive treatment to be more effective than conventional speech intervention alone, as both intervention and control groups made similar improvements in articulation after receiving treatments. One study reported a change in postintervention articulation test results but used an inappropriate statistical test and did not report the results clearly. None of the included studies examined the effects of NSOMTs on any other primary outcomes, such as speech intelligibility, speech physiology and adverse effects, or on any of the secondary outcomes such as listener acceptability.The RCT was judged at low risk for selection bias. The two quasi-randomised trials used randomisation but did not report the method for generating the random sequence and were judged as having unclear risk of selection bias. The three included studies were deemed to have high risk of performance bias as, given the nature of the intervention, blinding of participants was not possible. Only one study implemented blinding of outcome assessment and was at low risk for detection bias. One study showed high risk of other bias as the baseline characteristics of participants seemed to be unequal. The sample size of each of the included studies was very small, which means it is highly likely that participants in these studies were not representative of its target population. In the light of these serious limitations in methodology, the overall quality of the evidence provided by the included trials is judged to be low. Therefore, further research is very likely to have an important impact on our confidence in the estimate of treatment effect and is likely to change the estimate. AUTHORS' CONCLUSIONS: The three included studies were small in scale and had a number of serious methodological limitations. In addition, they covered limited types of NSOMTs for treating children with speech sound disorders of unknown origin with the sounds /s/ and /z/. Hence, we judged the overall applicability of the evidence as limited and incomplete. Results of this review are consistent with those of previous reviews: Currently no strong evidence suggests that NSOMTs are an effective treatment or an effective adjunctive treatment for children with developmental speech sound disorders. Lack of strong evidence regarding the treatment efficacy of NSOMTs has implications for clinicians when they make decisions in relation to treatment plans. Well-designed research is needed to carefully investigate NSOMT as a type of treatment for children with speech sound disorders.

Distribution of A(H1N1)pdm09 Influenza Vaccine: Need for Greater Consideration of Smaller Jails.

To identify factors associated with vaccine receipt among correctional facilities during the A(H1N1)pdm09 influenza pandemic, this study surveyed one third of U.S. correctional facilities. Analysis of the association of average daily population (ADP) on A(H1N1)pdm09 influenza vaccine receipt found that an ADP increase of 100 inmates resulted in a 32% increased likelihood of receiving influenza vaccine among smaller jails. Zero percent of large jails, 14% of federal prisons, 11% of nonfederal prisons, and 57% of small jails reported never receiving pandemic influenza vaccine. A qualitative assessment identified barriers to vaccine delivery, lessons learned from pandemic response, and recommendations for public health partners. Building stronger relationships between public health entities and correctional facilities to collaborate in influenza pandemic preparedness efforts may help protect correctional and community populations.

Temperature-sensitive mutants and revertants in the coronavirus nonstructural protein 5 protease (3CLpro) define residues involved in long-distance communication and regulation of protease activity.

Positive-strand RNA virus genomes are translated into polyproteins that are processed by viral proteases to yield functional intermediate and mature proteins. Coronaviruses (CoVs) carry genes that encode an nsp5 protease (also known as 3CLpro or Mpro) responsible for 11 maturation cleavages. The nsp5 structure contains two chymotrypsin-like domains (D1 and D2) and a unique domain (D3), and forms functional dimers. However, little is known of interactions or communication across the structure of the protease during nsp5 activity. Using reverse genetic mutagenesis of the CoV murine hepatitis virus (MHV) nsp5, we identified a new temperature-sensitive (ts) mutation in D2 of nsp5 (Ser133Ala) and confirmed a ts residue in D3 (Phe219Leu). Both D2-tsS133A and D3-tsF219L were impaired for viral replication and nsp5-mediated polyprotein processing at the nonpermissive temperature. Passage of tsS133A and tsF219L at the nonpermissive temperature resulted in emergence of multiple second-site suppressor mutations, singly and in combinations. Among the second-site mutations, a D2 His134Tyr change suppressed the ts phenotype of D2-tsS133A and D3-tsF219L, as well as the previously reported D2-tsV148A. Analysis of multiple CoV nsp5 structures, and alignment of nonredundant nsp5 primary sequences, demonstrated that ts and suppressor residues are not conserved across CoVs and are physically distant (>10 Å) from each other, from catalytic and substrate-binding residues, and from the nsp5 dimer interface. These findings demonstrate that long-distance communication pathways between multiple residues and domains of nsp5 play a significant role in nsp5 activity and viral replication, suggesting possible novel targets for non-active site inhibitors of nsp5.

Electropalatography for articulation disorders associated with cleft palate.

BACKGROUND: Cleft palate is the most common congenital deformity of the face. It could affect speech acquisition, resulting in articulation errors that could persist into adulthood. Electropalatography (EPG) has been used in speech therapy with individuals who have articulation problems that are unresponsive to "standard treatment" procedures. OBJECTIVES: To determine the effectiveness of speech intervention using electropalatography (EPG) for treating articulation errors in individuals with repaired cleft palate. SEARCH STRATEGY: The following databases were searched: CENTRAL 2008 (Issue1), MEDLINE 1966 to March 2008, EMBASE 1974 to March 2008, CINAHL 1982 to March 2008, PsycINFO 1967 to March 2008 and eight other databases. We handsearched Clinical Linguistics and Phonetics (1987 to 2008, Issue 2), Cleft Palate Journal/ Cleft Palate-Craniofacial Journal (1980 to 2008, Issue 1), and the International Journal of Language and Communication Disorders (1980 to 2008, Issue 1). We searched the EPG bibliography (Gibbon 2007). We reviewed reference lists of relevant articles and approached researchers to identify other possible published and unpublished studies. SELECTION CRITERIA: Randomised controlled studies comparing EPG intervention to no treatment, delayed treatment, "standard treatment", or alternative treatment techniques for managing articulation problems associated with cleft palate in children or adults. DATA COLLECTION AND ANALYSIS: One author searched the titles and abstracts and assessed trial quality. A second author checked judgements; disagreement was resolved through discussion. Three authors were available to examine any potential trials for possible inclusion in the review. MAIN RESULTS: One trial using parallel design met the inclusion criteria of this review; no meta-analysis was performed. The study reported that fewer therapy sessions were needed to achieve the treatment goals for the EPG therapy and frication display method (N = 2), followed by EPG therapy (N = 2) and "standard treatment" (N = 2). AUTHORS' CONCLUSIONS: The included trial was a small-scaled study and there were serious limitations in the design and methodology (e.g. allocation concealment was unclear, blinding of outcome assessor(s) was not ensured, few quantitative outcome measures were used, and the results were not reported as planned). Therefore, the current evidence supporting the efficacy of EPG is not strong and there remains a need for high-quality randomised controlled trials to be undertaken in this area.

Acoustic correlates of hypernasality.

The aim of this study was to apply one-third-octave analysis for measuring an acoustic correlate of hypernasality in the speech of adults with a range of aetiologies (dysarthria, maxillectomy and cleft palate). Subjects included 12 speakers with hypernasality and 12 normal controls. The speech material was the vowel /i/ segmented from two Cantonese single words produced by each speaker. The results showed that speakers with hypernasality had significantly higher energy level for the one-third-octave bands centred at 630, 800 and 1000 Hz, and significantly lower amplitude for the band centred at 2500 Hz than speakers with normal resonance. These results are in general agreement with past findings about nasalization of vowels. This study showed that one-third-octave analysis has high intrajudge reliability and is applicable to the speech of adults with hypernasality due to different etiologies.

Perceptual characteristics of Cantonese hypokinetic dysarthria.

The aims of this study were to provide a perceptual speech 'profile' for Cantonese speakers with hypokinetic dysarthria, to examine the reliability of non-expert listeners in perceptual judgements of dysarthric speech, and to investigate cross-language differences in profiles of hypokinetic dysarthria. Participants included 19 speakers with Parkinson's disease and 10 speech-language pathologists who served as listeners. Listeners rated 21 speech dimensions, using seven-point interval scales. Mean intralistener agreement was 94.52% and mean interlistener reliability was 0.88 (Cronbach's alpha). Mean scale values (MSV) for each dimension ranged from 3.37 to 1.36. The perceptual profile of Cantonese hypokinetic dysarthria was largely similar to profiles for English and Japanese speakers; notable differences are discussed. Possible reasons for the relatively high reliability obtained are presented.

Acoustic and perceptual analysis of the sibilant sound /s/ before and after orthognathic surgery.

PURPOSE: Orthognathic surgery may have a positive or negative effect on speech. Perceptual evaluation of presurgical and postsurgical articulation is difficult because speech errors, when they occur, are usually fricative distortions, which may be difficult to document reliably. In this study, acoustic analysis was used to supplement perceptual judgment of presurgical and postsurgical productions of /s/. SUBJECTS AND METHODS: The study population consisted of 9 Cantonese speakers undergoing osteotomy for Class III skeletal deformity and 9 age- and gender-matched adults with normal occlusion and speech. The speech sample consisted of 6 words with the initial sibilant sound /s/. Perceptual analysis included narrow phonetic transcription and classification of error types. Acoustic analysis included measurement of first and second spectral peaks, fricative duration, noise bandwidth, and noise-to-vowel decibel ratio. RESULTS: The results of the perceptual analysis showed a decrease in articulatory errors for the group after surgery, although 5 patients had no perceptual errors before surgery. Acoustic analysis showed significant differences between the experimental and control groups before surgery for 2 variables (spectral peak I and bandwidth). Three months after surgery there were no significant differences between the control group and the experimental group, except for bandwidth. Twelve months after surgery, there were significant differences between the 2 groups in noise bandwidth and spectral peak II. CONCLUSIONS: The results suggest a possible relapse at 1 year after surgery, based on spectral peak values. Osteotomy appears to result in a positive change in articulation for most patients, but speech outcome after osteotomy must be evaluated both 1 year and shortly after surgery.

Direct magnitude estimation and interval scaling of hypernasality.

Hypernasality is most commonly assessed using equal-appearing interval (EAI) scaling. Recently, the validity of EAI scaling for the evaluation of hypernasality has been questioned. The issue of validity rests on the psychophysical nature of the dimension to be rated. The purpose of this study was to compare EAI scaling with direct magnitude estimation (DME), in order to determine whether EAI scaling is a valid procedure for the evaluation of hypernasality. Connected speech samples from 20 individuals with repaired cleft palate and hypernasality were used. Twenty listeners undertook the listening tasks, which included EAI scaling, DME with modulus (DME-M), and DME without modulus (DME-WM). The results showed a curvilinear relationship between EAI and DME-M and between EAI and DME-WM, suggesting that EAI may not be a valid method for the evaluation of hypernasality; DME is recommended.