Using stepped-care approaches within internet-based interventions for youth anxiety: Three case studies.

Background There are a lack of clear guidelines for the dissemination of Internet-based cognitive behaviour therapy (ICBT) for childhood and adolescent anxiety in routine care. While self-guided ICBT has greater reach than therapist-guided ICBT, it is plagued by problems of low program adherence and many young people are not successfully treated. It is important that we identify models of ICBT that are accessible, but provide the right support, at the right time to those who need it. Stepped-care models of ICBT offer one potential solution. Objective This case study examined the application of stepped-care within an ICBT intervention for childhood and adolescent anxiety, in which young people were stepped up from self-guided to therapist-guided ICBT. Methods Three case studies are presented and include young males (aged 11–12 years) who participated in BRAVE Stepped-Care, a new ICBT program incorporating two treatment steps: Step 1 – five sessions of self-guided ICBT and Step 2 – five sessions of therapist-guided ICBT. Participants completed diagnostic assessments at pre- and post-treatment, along with a battery of self-report questionnaires. Step-up requirements were determined at a mid-treatment assessment. Treatment response was determined by change on diagnostic severity and presence of diagnosis and changes in self-reported anxiety symptoms (through T-scores and Reliable Change Indices). Results In-depth examination of the three case studies showed that decisions to step-up from Step 1 to Step 2 were complex and required consideration of program engagement and adherence, as well as changes on self-reported anxiety, behavioural indicators of anxiety and parent perspectives. Results showed that non-responders at mid-treatment who were stepped-up to therapist-guided ICBT after Step 1 were able to increase engagement and response to treatment in Step 2, such that they were free of their primary anxiety diagnosis at post-treatment. Conclusions The findings highlight the importance of early assessment of engagement and non-response within self-guided ICBT programs for youth anxiety and the positive changes that can subsequently occur when therapist-guidance is introduced mid-treatment for non-responders. The efficacy of stepped-care ICBT models needs to be confirmed in larger randomised controlled trials

Herbicide Evaluation in Arkansas Rice, 1997

Weed control is economically important for production of rice, a major crop in Arkansas. These findings summarize efforts of the team of Arkansas scientists working on weed control strategies for rice during 1997. Various technologies were evaluated in field studies at five locations involving the major weed problems and rice production systems used in the state. Results from these studies will add to the arsenal of weed control options for producers. Highlights include synergists and safeners for herbicides to aid in control of propanil-resistant barnyardgrass; herbicides and flooding techniques for control of red rice and other weeds; and the use of transgenic rice cultivars for broadspectrum weed control. The preliminary results reported here generally warrant further testing for more advanced findings and for the labeling of new technologies, and finally are the basis for updating safe, effective, and economical recommendations to Arkansas rice producers

Herbicide Evaluation in Arkansas Rice 2000

With the widespread development of resistance to propanil by barnyardgrass, the major weed in rice, research has been intensified in recent years to develop alternative weed control technology to the repeated use of propanil. The use of herbicides is economically important for production of rice. Field experiments are conducted annually in Arkansas to evaluate the activity of developmental and commercial herbicides for selective control of barnyardgrass and other weeds in rice. These experiments serve both industry and Arkansas agriculture by providing information on the selectivity of herbicides still in the developmental stage and by comparing the activity of these new herbicides with that of recommended herbicides

Herbicide Evaluation in Arkansas Rice, 1998

Weed control is economically important for production of rice, a major crop in Arkansas. These findings summarize efforts of the team of Arkansas scientists working on weed control strategies for rice during 1998. Various technologies were evaluated in field studies involving the major weed problems and rice production systems used in the state. Results from these studies will add to the arsenal of weed control options for producers. The preliminary results reported here generally warrant further testing for more advanced findings and for the labeling of new technologies and, finally, are the basis for updating safe, effective, and economical recommendations to Arkansas rice producers

The seasonality of tuberculosis, sunlight, vitamin D, and household crowding.

BACKGROUND: Unlike other respiratory infections, tuberculosis diagnoses increase in summer. We performed an ecological analysis of this paradoxical seasonality in a Peruvian shantytown over 4 years. METHODS: Tuberculosis symptom-onset and diagnosis dates were recorded for 852 patients. Their tuberculosis-exposed cohabitants were tested for tuberculosis infection with the tuberculin skin test (n = 1389) and QuantiFERON assay (n = 576) and vitamin D concentrations (n = 195) quantified from randomly selected cohabitants. Crowding was calculated for all tuberculosis-affected households and daily sunlight records obtained. RESULTS: Fifty-seven percent of vitamin D measurements revealed deficiency (<50 nmol/L). Risk of deficiency was increased 2.0-fold by female sex (P < .001) and 1.4-fold by winter (P < .05). During the weeks following peak crowding and trough sunlight, there was a midwinter peak in vitamin D deficiency (P < .02). Peak vitamin D deficiency was followed 6 weeks later by a late-winter peak in tuberculin skin test positivity and 12 weeks after that by an early-summer peak in QuantiFERON positivity (both P < .04). Twelve weeks after peak QuantiFERON positivity, there was a midsummer peak in tuberculosis symptom onset (P < .05) followed after 3 weeks by a late-summer peak in tuberculosis diagnoses (P < .001). CONCLUSIONS: The intervals from midwinter peak crowding and trough sunlight to sequential peaks in vitamin D deficiency, tuberculosis infection, symptom onset, and diagnosis may explain the enigmatic late-summer peak in tuberculosis

How Supervisors Influence Performance: A Multilevel Study of Coaching and Group Management in Technology-Mediated Services

This multilevel study examines the role of supervisors in improving employee performance through the use of coaching and group management practices. It examines the individual and synergistic effects of these management practices. The research subjects are call center agents in highly standardized jobs, and the organizational context is one in which calls, or task assignments, are randomly distributed via automated technology, providing a quasi-experimental approach in a real-world context. Results show that the amount of coaching that an employee received each month predicted objective performance improvements over time. Moreover, workers exhibited higher performance where their supervisor emphasized group assignments and group incentives and where technology was more automated. Finally, the positive relationship between coaching and performance was stronger where supervisors made greater use of group incentives, where technology was less automated, and where technological changes were less frequent. Implications and potential limitations of the present study are discussed

The use of routine outcome measures in two child and adolescent mental health services: a completed audit cycle

Background: Routine outcome measurement (ROM) is important for assessing the clinical effectiveness of health services and for monitoring patient outcomes. Within Child and Adolescent Mental Health Services (CAMHS) in the UK the adoption of ROM in CAMHS has been supported by both national and local initiatives (such as government strategies, local commissioning policy, and research). Methods: With the aim of assessing how these policies and initiatives may have influenced the uptake of ROM within two different CAMHS we report the findings of two case-note audits: a baseline audit conducted in January 2011 and a re-audit conducted two years later in December 2012-February 2013. Results: The findings show an increase in both the single and repeated use of outcome measures from the time of the original audit, with repeated use (baseline and follow-up) of the Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA) scale increasing from 10% to 50% of cases. Re-audited case-notes contained more combined use of different outcome measures, with greater consensus on which measures to use. Outcome measures that were applicable across a wide range of clinical conditions were more likely to be used than symptom-specific measures, and measures that were completed by the clinician were found more often than measures completed by the service user. Conclusions: The findings show a substantial improvement in the use of outcome measures within CAMHS. These increases in use were found across different service organisations which were subject to different types of local service priorities and drivers

Dysconnection in schizophrenia: from abnormal synaptic plasticity to failures of self-monitoring

Over the last 2 decades, a large number of neurophysiological and neuroimaging studies of patients with schizophrenia have furnished in vivo evidence for dysconnectivity, ie, abnormal functional integration of brain processes. While the evidence for dysconnectivity in schizophrenia is strong, its etiology, pathophysiological mechanisms, and significance for clinical symptoms are unclear. First, dysconnectivity could result from aberrant wiring of connections during development, from aberrant synaptic plasticity, or from both. Second, it is not clear how schizophrenic symptoms can be understood mechanistically as a consequence of dysconnectivity. Third, if dysconnectivity is the primary pathophysiology, and not just an epiphenomenon, then it should provide a mechanistic explanation for known empirical facts about schizophrenia. This article addresses these 3 issues in the framework of the dysconnection hypothesis. This theory postulates that the core pathology in schizophrenia resides in aberrant N-methyl-D-aspartate receptor (NMDAR)–mediated synaptic plasticity due to abnormal regulation of NMDARs by neuromodulatory transmitters like dopamine, serotonin, or acetylcholine. We argue that this neurobiological mechanism can explain failures of self-monitoring, leading to a mechanistic explanation for first-rank symptoms as pathognomonic features of schizophrenia, and may provide a basis for future diagnostic classifications with physiologically defined patient subgroups. Finally, we test the explanatory power of our theory against a list of empirical facts about schizophrenia