Children’s sensitivity to speaker accuracy and explanatory competence with biological concepts

This thesis investigated children’s selective trust in contexts that extend beyond a direct comparison of a distinctly accurate labeller with a distinctly inaccurate labeller in the domain of artifacts. First, it was examined whether children’s evaluations of informant trustworthiness is similar across the biological domain and the domain of artifacts. Second, it was investigated how children interpret novel labellers when compared to accurate and inaccurate labellers. Finally, children were presented with informants who provided functional or surface information for body parts to determine whether they prefer learning from informants who provided functional explanations. Across five experiments, children aged between 3 and 8 years of age (N = 379) were tested. The main findings were as follows: (a) 4- and 5-year-olds knew more about external body parts than internal organs; (b) 5-year-olds began to appreciate that speakers offering novel information were more trustworthy than those offering inaccurate information; (c) 4- to 8-year-olds had difficulty with distinguishing between informants who provided either functional explanations or obvious descriptions for highly unfamiliar organs; (d) however, when presented with informants who provided either functional or obvious information for highly familiar body parts, 8-year-olds (and to some extent, 5-year-olds) showed better recall of which informant provided a particular type of explanation, but they did not consider either informant to be a more trustworthy source. These findings indicate that children demonstrate selective trust in the biological domain, as well as in contexts that go beyond comparing accurate and inaccurate labellers. It is apparent that children are balanced in their evaluations of informants who provide new information, as well as those provide information that varies in explanatory depth. However, they are yet to fully consider functional explanations to be superior to superficial descriptions

Gender and obesity

The effects of olanzapine on the symptomatology of children with pervasive developmental disorder with emphasis on problems of communication and the safety of the drug were investigated in a 3-month open-label, open-dosage study. Participating in the study were 25 children age 6 to 16 years with a diagnosis of either autistic disorder or pervasive developmental disorder not otherwise specified. Psychometric measures included the Clinical Global Impression of Severity/Improvement, the Aberrant Behavior Checklist, and the TARGET (a checklist of five target symptoms). Communication skills were assessed during behavioral analysis of a playroom session. Safety measures included clinical chemistry variables, electrocardiography, the SimpsonAngus Neurological Rating Scale, the Barnes Akathisia Scale, and vital signs. Twenty-three children completed the study and showed significant improvement on three subscales of the Aberrant Behavior Checklist (Irritability, Hyperactivity, and Excessive Speech) and the TARGET. The final mean dose was 10.7 mg/day. Several aspects of communication were also improved after olanzapine treatment. However, only three children were considered responders in terms of the Clinical Global Impression of Severity/Improvement scores. The most important adverse events were weight gain, increased appetite, and loss of strength. Three children showed extrapyramidal symptoms that disappeared after the dose was lowered. Thus, while olanzapine was a relatively safe medication in children, its clinical relevance in children with pervasive developmental disorder may be limited

Using joint models to disentangle intervention effect types and baseline confounding: An application within an intervention study in prodromal Alzheimer's disease with Fortasyn Connect

Background: Many prodromal Alzheimer's disease trials collect two types of data: the time until clinical diagnosis of dementia and longitudinal patient information. These data are often analysed separately, although they are strongly associated. By combining the longitudinal and survival data into a single statistical model, joint models can account for the dependencies between the two types of data. Methods: We illustrate the major steps in a joint modelling approach, motivated by data from a prodromal Alzheimer's disease study: the LipiDiDiet trial. Results: By using joint models we are able to disentangle baseline confounding from the intervention effect and moreover, to investigate the association between longitudinal patient information and the time until clinical dementia diagnosis. Conclusions: Joint models provide a valuable tool in the statistical analysis of clinical studies with longitudinal and survival data, such as in prodromal Alzheimer's disease trials, and have several added values compared to separate analyses

Medication treatment in subjects with autistic spectrum disorders

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The autistic spectrum: subgroups, boundaries, and treatment.

There is consensus about the disorders that comprise the autistic spectrum, with autistic disorder, Asperger's disorder, and PDD-NOS as the most typical examples and Rett's disorder and disintegrative disorder as the other components. Important controversies regarding the precise definitions of autistic spectrum disorders and the boundaries between the milder manifestations of those disorders, particularly PDD-NOS, and non-autistic conditions have not been and cannot be resolved fully as long as there is no known biologic cause or consistent biologic or psychological marker. This includes issues as basic as whether the autistic spectrum is a predominantly unitary entity or a collection of more or less similar phenotypes with multiple, varying etiologies. This is why the highest long-term priority in the area of definite diagnosis is the search for biologic marker(s) for autism and related autism spectrum disorders [91]. In the absence of a medical test to unequivocally diagnose autism, definitions of autism and related conditions are based only on manifestations in overt behavior, with all the unreliability this entails. In the future, the discovery of biologic correlates, causes, and pathogenetic pathways will undoubtedly change the way in which autism is diagnosed and lead to a new nosology [95]. Until that time the definitions in the current versions of the classification systems should be considered in a state of evolution. The key problem of the current classification systems is the fact that the boundaries between the various disorders are fuzzy. Instead of a categorical approach, a more useful description might be that of "autistic spectrum disorder," which reflects the range of severity of symptoms. Such a dimensional understanding of PDD is useful to clinicians, who may otherwise use nonspecific terms to avoid the categorical diagnosis of autism [31]. Rutter and Schopler [96] argued for separate clinical and research schemes because clinical and research needs are different. For research purposes it is desirable to have as much direct comparability across studies as possible. The focus is on a high degree of homogeneity within diagnostic groupings. A price must be paid for this detailed specification, and the main cost lies in the proportion of cases left undiagnosed. For example, there may be good scientific reasons for a narrowly defined categorical diagnosis that includes only individuals who definitely and clearly have a specifically defined condition and excludes individuals who may have the condition. For clinicians and educators, classification helps guide the selection of treatments for an individual. From this point of view, broader diagnostic concepts may be most appropriate [95]

Improving access to pulmonary rehabilitation in rural and remote Australia

Pulmonary rehabilitation, consisting of exercise training and education, is one of the most effective strategies for improving the health outcomes of people with chronic obstructive pulmonary disease (COPD) and reducing associated healthcare costs. Prior to the work presented in this thesis a description of the structure and content of pulmonary rehabilitation programs in Australia had not been published. In addition, whether existing programs met Australian recommendations for practice such as those contained in the Pulmonary Rehabilitation Toolkit, was unknown. Despite the significant benefits for both individuals with COPD and the community, access to pulmonary rehabilitation is limited, particularly for those in rural and remote regions. A lack of adequately trained healthcare professionals may contribute to difficulties with establishing and maintaining pulmonary rehabilitation. However, the effect of healthcare professional training on the availability of pulmonary rehabilitation had not been previously investigated. There were no published reports documenting existing knowledge and skill levels, evaluating training strategies to up-skill rural/remote healthcare professionals or evaluating the impact of such training on the delivery of pulmonary rehabilitation. The aims of the studies presented in this thesis were to: describe the current provision of pulmonary rehabilitation in Australia and the alignment of these pulmonary rehabilitation programs with evidence-based recommendations; determine the level of knowledge and skills of rural and remote healthcare professionals in the management of people with chronic lung disease; investigate the ability of an educational training program for healthcare professionals to improve knowledge and confidence and improve the availability and delivery of pulmonary rehabilitation in rural and remote regions and explore the attitudes, opinions and concerns of healthcare professionals regarding the delivery of pulmonary rehabilitation. The first study (Chapter 2) was a cross sectional, observational study using a purpose designed anonymous paper-based survey. The national database of pulmonary rehabilitation programs, maintained by Lung Foundation Australia (LFA), was used to identify known programs in all states and territories of Australia. All pulmonary rehabilitation programs listed on the database at that time were included (n=193). Healthcare professionals who coordinated pulmonary rehabilitation were invited to participate. This study had a response rate of 83% (n=163) and all states and territories in Australia were represented. The responses enabled the structure and content of Australian pulmonary rehabilitation programs to be elucidated. Most Australian pulmonary rehabilitation programs broadly met recommendations for practice contained in the Pulmonary Rehabilitation Toolkit in terms of included components (exercise training and education), program length, patient assessment and exercise training (duration, frequency and mode). Many respondents were not aware of major evidence-based practice guidelines (including the Pulmonary Rehabilitation Toolkit). Interestingly, despite not being aware of guidelines, most respondents indicated that they perceived a gap between current evidence and their practice in terms of exercise prescription and training. The studies presented in Chapters 4-7 were undertaken as individual components of a mixed methods study to evaluate the impact of the Breathe Easy Walk Easy (BEWE) program on healthcare professional knowledge and confidence, service delivery and patient outcomes in rural and remote Australian regions. The BEWE program was an interactive education and training program related to providing components of assessment and management (in particular pulmonary rehabilitation) for people with chronic respiratory disease. The BEWE program consisted of a training workshop, access to online resources, provision of community awareness-raising materials and ongoing telephone/email support. Details of the development of the BEWE program are presented in Chapter 1. Further information regarding the content and structure of the BEWE program along with relevant methods for the studies contained in Chapters 4-7, are presented in Chapter 3. The evaluation process was conducted by a researcher (the PhD candidate) who was independent of the development and delivery of the BEWE program. The study presented in Chapter 4 was a descriptive cross-sectional, observational survey design using a written anonymous questionnaire. Participants were healthcare professionals (n=31) who registered to attend the BEWE program initial workshop in either one rural or one remote Australian region. The main outcomes were participant attitudes, objective knowledge (case vignette-based) and self-rated experience, training, and levels of confidence. Participants were from a variety of professional backgrounds (allied health, medical, nursing) but were predominantly nurses (n=13) or physiotherapists (n=9). The main findings of this study were that that rural and remote healthcare professionals had low levels of experience, training, knowledge and confidence in providing components of management for people with COPD. Most participants reported that they had minimal or no experience or training in this area of practice. The scores in the measured knowledge quiz were generally poor, with mean knowledge score (number of correct answers out of 19) being 8.5 (SD=4.5). There were higher numbers of correct responses for questions relating to COPD disease pathophysiology and diagnosis than for questions relating specifically to pulmonary rehabilitation. In addition, most participants reported particularly low confidence in the delivery of pulmonary rehabilitation. Based on the findings of the study, the need for an education and training program for rural and remote healthcare professionals in the evidence-based management of people with COPD with an emphasis on pulmonary rehabilitation was evident. The effects of the delivery of an education and training program on healthcare professional knowledge and confidence in the management of people with COPD and on the availability of pulmonary rehabilitation were investigated and are presented in Chapter 5. This study was a quasi-experimental, before and after repeated measures design. Healthcare professionals (n=33) from various backgrounds who participated in the BEWE program were eligible to participate. The BEWE program was delivered in one rural and one remote region. Participant knowledge, confidence and attitudes were assessed via anonymous written questionnaire before, immediately after and at three and 12 months following the BEWE workshop. Participation in the BEWE program resulted in significant improvements in participants’ self-rated knowledge and confidence immediately after the workshop, and at three and 12 month follow-up. Measured knowledge (case vignette score out of 19) improved significantly immediately after the workshop compared to before (mean difference 7.6 correct answers, 95% CI 5.8 to 9.3). At 12-month follow-up, three locally run pulmonary rehabilitation programs had been established in participating regions. The availability of pulmonary rehabilitation following delivery of the BEWE program, as well as patient outcomes and the factors contributing to the change in service delivery were further explored and results are presented in Chapter 6. Data were collected regarding the provision of pulmonary rehabilitation services before and after delivery of the BEWE program and patient outcomes (six-minute walk test and health related quality of life) before and after pulmonary rehabilitation. Pulmonary rehabilitation was not available in any of the participating sites before the BEWE program. At 12-month follow-up three sites had established locally-run pulmonary rehabilitation programs which had a structure and content broadly meeting Australian practice recommendations for pulmonary rehabilitation. Initial patient outcome data for the six-minute walk test and the St George’s Respiratory Questionnaire demonstrated evidence of the effectiveness of these pulmonary rehabilitation programs in improving functional exercise capacity and health related quality of life. Providing targeted specific training, the retention of key staff and strong local healthcare organisational support were important factors which contributed to the successful establishment of pulmonary rehabilitation. A study involving interviews with key healthcare professionals involved in the delivery of pulmonary rehabilitation in rural and remote regions was conducted and is presented in Chapter 7. Those healthcare professionals who participated in the BEWE program and who were identified as key informants, were invited to participate in semi-structured interviews. The purpose of the interviews was to gain a deeper understanding of the participants’ attitudes and opinions regarding developing, establishing and delivering pulmonary rehabilitation in rural and remote regions. This study was designed to add perspective to the quantitative data rather than to inform the design of the evaluation process. Interviews occurred at three and 12 months following the BEWE workshop in the remote region and at 12 months following the BEWE workshop in the rural region. Interviews were recorded and transcribed verbatim. A process of thematic analysis was used to analyse the transcripts. Healthcare professional staffing levels, time and case load constraints, knowledge and confidence, ensuring sustainability, individual and community attitudes, and practical issues related to the setting, structure and content of pulmonary rehabilitation were identified as the main concerns of informants. The results of this study indicate that dedicated funding to support additional healthcare professional staffing and to assist with providing specific education and training may facilitate the availability and delivery of pulmonary rehabilitation in rural and remote regions. The body of work contained in this thesis has contributed to a greater knowledge of the practice and availability of pulmonary rehabilitation in the Australian rural and remote context and has provided evidence that the provision of a training program for healthcare professionals can facilitate the delivery of effective pulmonary rehabilitation in rural and remote Australian regions

Is 18 months too early for the CHAT?

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Increasing the use of intervention research evidence in public health policy and practice: roles of policy makers, practitioners, researchers and funders in research generation and utilization

The effective application of research evidence to guide public health policy and practice is an ongoing and significant challenge which was investigated in this thesis through 6 separate but related studies organised under 4 research themes: 1) frameworks for translating research evidence into policy and practice; 2) types of research used to inform public health action; 3) scaling up public health action; and 4) impacts of research. Methodologies used included systematic reviews, case studies, bibliometric and content analysis, document review, surveys, in-depth interviews and expert consensus processes. It was found that the translation models can be used to better understand the use of research evidence in ‘real world’ policy and practice. A bibliomteric analysis found that intervention research remains only a small proportion of published literature across health issues and timeframes (between 10-23%). Studies that focused on scaling up resulted in the development of a guide and concluded that more intervention research that focuses on the effectiveness, reach, and costs of operating at scale and key service delivery issues (including acceptability and fit of interventions and delivery models) will increase relevance and ultimately usability of research evidence for scaling up population health action. Finally, an assessment of the impacts of a government applied research funding scheme found that projects achieved the greatest policy and practice impacts if they engaged end-users from the inception, utilized existing policy networks and structures in research development and dissemination. A better understanding of the science of implementation and impacts of research is essential to maximising the policy and practice related returns of research investment

Different stability of social-communication problems and negative demanding behaviour from infancy to toddlerhood in a large Dutch population sample

Contains fulltext : 136250.pdf (publisher's version ) (Open Access)BACKGROUND: Little is known about the stability of behavioural and developmental problems as children develop from infants to toddlers in the general population. Therefore, we investigated behavioural profiles at two time points and determined whether behaviours are stable during early development. METHODS: Parents of 4,237 children completed questionnaires with 62 items about externalizing, internalizing, and social-communicative behaviour when the children were 14-15 and 36-37 months old. Factor mixture modelling identified five homogeneous profiles at both time points: three with relatively normal behaviour or with mild/moderate problems, one with clear communication and interaction problems, and another with pronounced negative and demanding behaviour. RESULTS: More than 85% of infants with normal behaviour or mild problems at 14-15 months were reported to behave relatively typically as toddlers at 36-37 months. A similar percentage of infants with moderate communication problems outgrew their problems by the time they were toddlers. However, infants with severe problems had mild to severe problems as toddlers, and did not show completely normal behaviour. Improvement over time occurred more often in children with negative and demanding behaviour than in children with communication and interaction problems. The former showed less homotypic continuity than the latter. CONCLUSIONS: Negative and demanding behaviour is more often transient and a less specific predictor of problems in toddlerhood than communication and interaction problems