Marlene M. Eisenberg

Child Care Research: Issues, Perspectives, and Results

CONTEXTS OF CHILD CARE RESEARCH 613 DEFINITION AL ISSUES . . . . . . . . . . 615 CHILD CARE AS RlSK. 618 CHILD CARE OUTCOMES . ...... . . . . . . .. ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 626 SCIENTIFIC IMPLICATIONS . . . 636 PUBLIC POLICY 637

Examining Racial Disparities in HIV : Lessons From Sexually Transmitted Infections Research

Racial differences in the prevalence and incidence of HIV infection and AIDS diagnoses in the United States are striking. These differences have been recognized for nearly 20 years, yet they are not well investigated. In this article, we examine 15 factors identified in the sexually transmitted infection (STI) literature to explain the presence of racial/ethnic disparities in STIs. We review findings from these studies and offer suggestions for future research, with the goal of further understanding and reducing disparities in HIV. In general, the STI literature shows that an evaluation of individual behavior is necessary but insufficient on its own to account for racial/ethnic disparities in STIs. Population parameters should be included within models that traditionally include individual-level factors. The 15 factors can be categorized into 3 broad overarching themes: behavioral, prevention participation, and biologic explanations of differentials in STI transmission and infection. Future research that focuses on only 1 of the 15 factors discussed in this review, to the exclusion of others, is likely to yield poor outcomes. Conversely, an emphasis on the interactions of several factors is more likely to produce effective public health interventions and reductions in HIV transmission.PURPOSE To clarify the roles of objective signs and subjective symptoms in the diagnosis and management of dry eye by describing their use by a group of expert practitioners. Dry eye signs and symptoms do not always correlate well, and there is currently some controversy over the ideal roles of signs and symptoms and their actual use in clinical practice. METHODS A balanced panel of 16 participants in a scientific roundtable on dry eye reviewed 4 patient case studies and completed surveys ranking common diagnostic procedures assessing symptoms and signs by the order in which they would be used. RESULTS Symptom assessment was the predominant diagnostic method. The objective tests most commonly used during the initial examination were tear breakup time (93%), corneal staining (85%), tear film assessment (76%), conjunctival staining (74%), and the Schirmer test (54%). Most panelists used multiple tests, with a median of 6 tests used in the initial examination. CONCLUSIONS Subjective symptoms and objective signs are both important in the diagnosis and management of dry eye, with the patients symptoms and history playing a critical role. Most clinicians use objective signs in dry eye management. However, currently available diagnostic tests do not correlate reliably with symptom severity. Research aimed at developing accurate, objective, responsive measures of dry eye severity is needed.

The MacArthur adjudicative competence study: development and validation of a research instrument.

Assessment of competence to stand trial is a common evaluation that can have substantial consequences for defendants and the criminal justice system. Despite a voluminous literature, much remains unknown. An obstacle to progress in understanding what is better termed “adjudicative competence” is the absence of structured, standardized research measures for assessment of defendants. This article presents the legal framework, assessment strategy, instrument description, psychometric properties, and construct validation of the MacArthur Structured Assessment of the Competencies of Criminal Defendants (MacSAC-CD). The measures meet or exceed accepted indices of internal consistency, and interscorer agreement. Observed patterns of correlations among measures support the underlying theoretical structure of competence-related abilities. Moreover, the MacSAC-CD distinguishes groups of competent and incompetent defendants; reflects changes in competence status; and correlates positively with clinical judgments, negatively with psychopathology and impaired cognitive functioning, and negligibly with cynicism toward the justice system

The MacArthur adjudicative competence study: diagnosis, psychopathology, and competence-related abilities

A set of measures assessing abilities related to legal standards for competence in the adjudicative process were administered to mentally-disordered criminal defendants with diagnoses of schizophrenia, affective disorder, other psychiatric disorders, and to criminal defendants without diagnosed mental disorder. Mentally-disordered defendants were recruited from two groups: those who had been committed for restoration of competence and those who had been identified by jail personnel as mentally ill. Significant impairments in competence-related abilities were found for approximately half of the defendants with schizophrenia. Defendants with schizophrenia scored lower on measures of understanding, reasoning, and appreciation related to the adjudication process. The association between symptoms and competence-related abilities was explored within diagnostic groups. Conceptual disorganization was found to be inversely correlated with performance on all measures in both defendants with schizophrenia and those with affective disorders. For other psychotic symptoms, differing patterns of correlations were found in the two major diagnostic groups. The implications for policy designed to safeguard the rights of defendants to be tried while competent are discussed.

The Validity of Mental Patients' Accounts of Coercion-Related Behaviors in the Hospital Admission Process

Although the recent development of a measure for perceived coercion has led to great progress in research on coercion in psychiatric settings, there still exists no consensus on how to measure the existence of real coercive events or pressures. This article reports the development of a system for integrating chart review data and data from interviews with multiple participants in the decision for an individual to be admitted to a psychiatric hospital. The method generates a “most plausible factual account” (MPFA). We then compare this account with that of patients, admitting clinicians and other collateral informants in 171 cases. Patient accounts most closely approximate the MPFA on all but one of nine dimensions related to coercion. This may be due to wider knowledge of the events surrounding the admission.

Treatment Considerations for HIV-Infected Individuals with Severe Mental Illness

There has been a general recognition of a syndemic that includes HIV/AIDS and serve mental illnesses including schizophrenia, major depression, bipolar disorder, post-traumatic stress disorder, and others. The pathophysiology and direction of effects between severe mental illness and HIV infection is less clear however, and relatively little work has been done on prevention and treatment for people with these complex, co-occurring conditions. Here we present the most recent work that has been published on HIV and mental illness. Further, we describe the need for better treatments for “triply diagnosed persons”; those with HIV, mental illness, and substance abuse and dependence. Finally, we describe the potential drug-drug interactions between psychotropic medications and anti-retrovirals, and the need for better treatment guidelines in this area. We describe one example of an individually tailored intervention for persons with serious mental illness and HIV (PATH+) that shows that integrated community-based treatments using advanced practice nurses (APNs) as health navigators can be successful in improving health-related quality of life and reducing the burden of disease in these persons.

Increasing Quality of Life and Reducing HIV Burden: The PATH+ Intervention

The heightened risk of persons with serious mental illness (SMI) to contract and transmit human immunodeficiency virus (HIV) is a public health problem. Our objective was test the effectiveness of a community-based advanced practice nurse intervention to promote adherence to HIV and psychiatric treatment regimens call Preventing AIDS Through Health for Positives (PATH+). We enrolled 238 HIV-positive subjects with SMI who were in treatment at community HIV provider agencies from 2004 to 2009. Participants in the intervention group were assigned an advanced practice nurse who provided community-based care management at a minimum of one visit/week and coordinated their medical and mental healthcare for 12 months. A parallel process latent growth curve model using three data points for biomarkers (baseline, 12 and 24 months) and five data points for health related quality of life (baseline, 3, 6, 12, and 24 months) showed moderate to excellent fit for modeling changes in CD4, viral load, and mental and physical SF-12 subscales. Results suggest that positive effects for PATH+ persisted at 24 months; 12 months after the intervention ended. This project demonstrates the effectiveness of a nurse-led, community-based, individually tailored adherence intervention. We demonstrated improved outcomes in individuals with HIV/SMI and regarding health-related quality of life and reductions in disease burden.

Tailored Treatment for HIV+ Persons with Mental Illness: The Intervention Cascade

Abstract:The public health literature demonstrates disturbingly high HIV risk for persons with a serious mental illness, who are concurrently comorbid for substance abuse. Many HIV positives have not been tested and therefore do not know their status, but for individuals who are triply diagnosed, adherence to HIV treatment results in meaningful reductions in viral loads and CD4 counts. Barriers to treatment compliance are reviewed, low-threshold/low-intensity community-based interventions are discussed, and preliminary evidence is presented for the efficacy of the intervention cascade, defined as an integrated intervention delivered by specially trained nurses who individualize a treatment compliance intervention in real time as an adaptive response to demand characteristics of the individual.

HIV and mental illness: opportunities for prevention.

The fields of public health and mental health have theoretically been collaboratingsince thebeginningsofCommunityPsychology.However, the true integration of the two fields is only now being realized as viable public health interventions for HIV/AIDS take hold and the consequencesof thatdiseaseasachronic illnessareobservedwithin thosediagnosed with serious mental illnesses. Mental health status not only mediates risk behaviors, but positive serostatus also has direct and indirecteffectsonmentalhealth.TheavailabilityofmoreeffectiveHIVtreatments has reduced mortality, resulting in a growing number of people living with HIV, even as the incidence of new cases decreases in the UnitedStates.Assuch,amorecompleteunderstandingof the interactions between mental health status and HIV serostatus is of increasing importance. Persons with mental illness have not traditionally been thought of as a group at risk for becoming infected with HIV in the same way as have othergroupssuchaspeoplewhoinjectdrugs,gaymen,andpeoplewithmultiple sex partners, but there is increasing recognition that mental illness makes people more vulnerable to contracting HIV and AIDS. This vulnerability isdue inpart toadisadvantagedsocial statusandpovertywhich places them in contact with other high risk populations. Persons with mental illnesses have also been found to have higher rates of substance

Coercion to Inpatient Treatment

Debate over the role of coercion in mental hospital admission frequently invokes the prospective patient’s moral right to decision-making autonomy and individual dignity (e.g., Blanch & Parrish, 1993; Wertheimer, 1993). But empirical arguments for or against coercion are often pressed as well. The empirical issue most often raised is whether coerced treatment “works.” On one side, some patient advocates argue that the alleged benefits of treatment to the patient or others can be negated by patients’ feelings of alienation and dissatisfaction, as a result of which patients become unlikely to comply with treatment as soon as the coercion is lifted (cf. National Center for State Courts, 1986). Even if coerced treatment benefits those on whom it is imposed, other prospective patients may be deterred from seeking treatment voluntarily for fear that they too will be committed (Campbell & Schraiber, 1989). On the other side, a recent report by the Group for the Advancement of Psychiatry (1994), though it grants that “there seems to be a kind of embarrassment about situations in which the patient did not enter treatment entirely on his or her own initiative” (p. x), concludes that “sometimes involuntary psychiatric treatment is necessary, can be effective, and can lead to freedom from the constraints of illness. Conversely, tight restrictions against coercive treatment can have disastrous consequences” (p. 43).