Kathleen R. Delaney

The long-term efficacy of a behavioral parent training intervention for families with 2-year-olds.

The effectiveness of a behavioral parent training (BPT) intervention for improving maternal self-efficacy, maternal stress, and the quality of mother-toddler interactions has been demonstrated (Gross, Fogg, & Tucker, 1995). The 1-year follow-up of the 46 parents of toddlers (assigned to an intervention or comparison group) who participated in that study is reported. It was hypothesized that (a) BPT would lead to enduring positive changes in parenting self-efficacy, parenting stress, and parent-toddler interactions; and (b) the amount of parent participation in the intervention would be correlated with greater gains in parent-child outcomes at 1 year. All the families were retained and significant gains in maternal self-efficacy, maternal stress, and mother-child interactions were maintained. Minimal BPT effects were found for fathers. BPT dosage was related to reductions in mother critical statements and negative physical behaviors at 1-year postintervention. The findings are consistent with self-efficacy theory and support parenting self-efficacy as a target for BPT in families of young children.

Keeping the Unit Safe: Mapping Psychiatric Nursing Skills

BACKGROUND: The de-escalation skills of inpatient psychiatric nurses are considered key to violence prevention. Yet their efficacy and translation into practice remains in question. OBJECTIVE: The aim of this study is to describe the de-escalation skills of psychiatric nurses. In the process, the investigators uncover ways nurses interact with patients to create and maintain a safe environment. STUDY DESIGN: Grounded theory methods are used to collect and analyze data derived from staff interviews and direct observation of milieu interactions. RESULTS: Staff behaviors are seen to create a safe milieu and promote a positive unit culture. Skills critical to maintaining a safe environment center on nurses’ awareness, attending, caring, and connecting. CONCLUSIONS: The behaviors identified in this study are at the heart of managing the clinical context of acute psychiatric units. Attention to these behaviors is especially critical in light of the staff expertise needed to keep the unit safe.

Long-term outcomes of adaptive functions for children with mucopolysaccharidosis I (Hurler syndrome) treated with hematopoietic stem cell transplantation.

ABSTRACT. Advances in medical treatment have prolonged the lives of children with Hurler syndrome or mucopolysaccharidosis I requiring increased attention to the assessment of their long-term outcomes and functional abilities. Adaptive functions are critical for understanding functional outcomes after treatment and developing focused interventions. We investigated the development of various adaptive functions in children who have had hematopoietic stem cell transplant (HSCT) for Hurler syndrome and risk factors that are associated with the development of these functions. We examined the development of 41 children who had 3 or more Vineland Adaptive Behavior Scales records assessed before and after transplant. Communication, daily living skills, socialization, and motor functions were measured. While standard scores decline over time, development of skills continue with a slower than average rate compared with peers. A cross-sectional nontransplanted comparison group showed more deficits after age 2 years than the transplanted group. In contrast to cognitive ability, age at transplant was not significantly associated with ultimate adaptive level. Baseline cognitive level before HSCT and growth of cognition after HSCT were associated with adaptive functions especially for communication and daily living skills. Socialization was predicted by cumulative medical risk factors, likely due to restricted social exposure in children with complicated transplant courses. Overall, measurement of adaptive behaviors demonstrated that HSCT allows long-term slow improvement of functional outcomes for children with Hurler syndrome. Children with Hurler syndrome with good cognitive levels before HSCT and continued growth of cognition after HSCT show good adaptive functions. Although cognitive and orthopedic problems as well as medical complications limit adaptive ability, identifying these problems early allow beneficial targeted interventions.

Keeping the Unit Safe: A Grounded Theory Study

It is critical for researchers to develop multidimensional models of prevention that reflect the complexity of the organization of a psychiatric unit. OBJECTIVE: The objective of the study was to develop a midrange theory of violence prevention on inpatient psychiatric units. DESIGN: Grounded theory methods were used for data collection and analysis. Data collection and analyses were conducted simultaneously, and the constant comparative method was used for analysis. RESULTS: The staff and patients were observed on two inpatient psychiatric units for approximately 400 hours. A total of 28 patients and staff was interviewed. The basic social process that emerged from the study was Keeping the Unit Safe. The dimensions of this process are ideology, people, space, and time. CONCLUSION: The findings from this study can be used to assess the safety of particular units and to identify changes that could potentially influence the outcome of patient and staff safety.

Keeping the Unit Safe: The Anatomy of Escalation

BACKGROUND: Escalation has been depicted as a linear trajectory of behavioral eruption beginning with agitation and proceeding until the patient is out of control. This notion has influenced current descriptions of de-escalation strategies. OBJECTIVES: The study objective was to understand the context and conditions that influence how nursing staffs manage patients who are escalating out of control. DESIGN: Methods consistent with grounded theory were used to collect and analyze the data. Patient—staff interactions were observed for more than 400 hours on inpatient units. Sixteen staff members and 12 patients were interviewed. FINDINGS: Data analysis revealed a nonlinear process of escalation and de-escalation. Two conditions that influenced strategies used by staff members were the type and the trajectory of escalation. This report focuses on patterns of patient escalation. CONCLUSION: The data revealed a complex escalation and de-escalation process that necessitates ongoing assessments of patient status and the milieu and individualizing staff responses. J Am Psychiatr Nurses Assoc, 2007; 13(1), 42-52.

A Double-Blind, Placebo-Controlled Crossover Study Investigating the Effect of Porcine Secretin in Children with Autism:

Objectives: A recent patient series reported the incidental findings of improved social and language skills in 3 children with autistic spectrum disorders after the administration of secretin, a peptide hormone. However, a subsequent study did not find evidence for a drug effect. Parents are seeking treatment with secretin despite the absence of empirical investigations demonstrating amelioration in autism symptomology. In order to more precisely measure the effects of secretin, this study investigated the effect of a single intravenous dose of porcine secretin on 12 autistic children through a randomized, double-blind, placebo-controlled, crossover study. Children were assessed on objective language and on social, neuropsychological, and gastrointestinal measures to evaluate drug effects. The study was conducted over a 16-week trial. The results indicated that significant differences were not observed on the majority of the dependent variables. Statistically significant differences were observed on measures of positive affect and activity level following secretin infusion. In general, the autistic children did not demonstrate the improvements described in the initial retrospective report.

The effect of intimate partner violence education on nurse practitioners' feelings of competence and ability to screen patients.

This study examined the prevalence of formal intimate partner violence (IPV) education during basic and advanced practice programs and its effect on the likelihood of screening for IPV. A national, random sample of 553 nurse practitioners completed a written survey documenting their IPV educational experiences in both their basic and advanced practice programs. Although 77.9% had received IPV education at some point in their nursing education, this education had a far greater effect on their subjective feelings of competence and comfort in working with IPV patients than it had on the likelihood of their screening or identifying IPV victims in their practice. Nurse educators must provide students with the words, body language, and screening measures to use to screen effectively. Study implications for nursing education, limitations, and recommendations are discussed.

Health Care Reform and the Federal Transformation Initiatives: Capitalizing on the Potential of Advanced Practice Psychiatric Nurses

In the last decade the US federal government proposed a transformation vision of mental health service delivery; patient-centered, evidence-based and recovery oriented treatment models. Health care reform brings additional expectations for innovation in mental/substance use service delivery, particularly the idea of creating systems where physical health, mental health and substance use treatment is fully integrated. Psychiatric nurses, as one of the four core US mental health professions, have the potential to play a significant role in the both the transformation initiative and health care reform vision. However, psychiatric nurses, particularly advanced practice psychiatric nurses, are an untapped resource due in part to significant state regulatory barriers that limit their scope of practice in many states. The purpose of this paper is to document what is currently known about advanced practice psychiatric nurses and discuss policy implications for tapping into the strengths of this workforce. Strategies for facilitating utilization of advanced practice psychiatric nurses discussed.

Neurocognition across the spectrum of mucopolysaccharidosis type I: Age, severity, and treatment.

OBJECTIVES Precise characterization of cognitive outcomes and factors that contribute to cognitive variability will enable better understanding of disease progression and treatment effects in mucopolysaccharidosis type I (MPS I). We examined the effects on cognition of phenotype, genotype, age at evaluation and first treatment, and somatic disease burden. METHODS Sixty patients with severe MPS IH (Hurler syndrome treated with hematopoietic cell transplant and 29 with attenuated MPS I treated with enzyme replacement therapy), were studied with IQ measures, medical history, genotypes. Sixty-seven patients had volumetric MRI. Subjects were grouped by age and phenotype and MRI and compared to 96 normal controls. RESULTS Prior to hematopoietic cell transplant, MPS IH patients were all cognitively average, but post-transplant, 59% were below average, but stable. Genotype and age at HCT were associated with cognitive ability. In attenuated MPS I, 40% were below average with genotype and somatic disease burden predicting their cognitive ability. White matter volumes were associated with IQ for controls, but not for MPS I. Gray matter volumes were positively associated with IQ in controls and attenuated MPS I patients, but negatively associated in MPS IH. CONCLUSIONS Cognitive impairment, a major difficulty for many MPS I patients, is associated with genotype, age at treatment and somatic disease burden. IQ association with white matter differed from controls. Many attenuated MPS patients have significant physical and/or cognitive problems and receive insufficient support services. Results provide direction for future clinical trials and better disease management.

Acquired Autistic Behaviors in Children with Mucopolysaccharidosis Type IIIA

OBJECTIVES To assess autism spectrum disorder (ASD) behaviors in children with mucopolysaccharidosis type IIIA (MPS IIIA) using a standard measure, understand the behavioral evolution of the disease, and provide specific guidelines for diagnosis. STUDY DESIGN Children (n = 21) with documented enzyme deficiency and SGSH gene mutations, cognitive age-equivalent >12 months, and early onset were administered the Autism Diagnostic Observation Schedule (ADOS) (module 1) and Bayley Scales of Infant Development-Third Edition. ADOS Social Affect and Restricted Repetitive Behavior total scores, as well as Bayley Scales of Infant Development-Third Edition cognitive age-equivalent scores, are reported using descriptive statistics and graphic presentations. RESULTS Thirteen of the 21 children evaluated met the ADOS criteria for ASD/autism. ADOS score was strongly associated with age; all 11 children aged >46 months met the criteria, compared with only 2 of 10 aged <46 months. Social and affective abnormalities were most frequent; restricted interests and repetitive behaviors were largely absent. Lack of cognitive growth paralleled ADOS score. CONCLUSION An increased incidence of ASD-like social behaviors was seen at age 3-4 years in children with early-onset MPS IIIA. Although more frequent in the severely impaired children, ASD-like behaviors were observed across the entire range of cognitive impairment. Clinicians must be aware that when a child acquires ASD-like behaviors, MPS IIIA should be included in the differential diagnosis.