Evidence-based management and intervention for autism spectrum disorders

Autism Spectrum Disorder (ASD) is diagnosed along a continuum of behavioural variants in social communication and repetitive behaviours [96]. Most individuals on the autism spectrum also experience differences in sensory perception. Some individuals on the spectrum are ‘high-functioning’ and able to cope in every day environments, while others are severely affected, non-verbal, and may have co-occurring diagnoses, such as intellectual disability, epilepsy, and/or obsessional, conduct, or mental health disorders. These individuals require substantial support, caring and careful management, and evidence-based, effective interventions.

Utilising a computer game as a therapeutic intervention for youth in residential care: Some preliminary findings on use and acceptability

Mental illness is common amongst young people living in residential care, many of whom are reluctant to avail of therapeutic help. The potential value of computer games as therapeutic tools for these young people has received very little attention, despite indications of their potential for promoting engagement in therapeutic work and improving mental health outcomes. This study aimed to fill this research gap through the development, introduction, and preliminary evaluation of a therapeutic intervention in group care settings. The intervention incorporated a commercially available computer game (The SIMS Life Stories™) and emotion regulation skill coaching. Qualified residential social workers were trained to deliver it to young people in three children's homes in Northern Ireland, where therapeutic approaches to social work had been introduced. The research was framed as an exploratory case study which aimed to determine the acceptability and potential therapeutic value of this intervention. The evidence suggests that computer-game based interventions of this type may have value as therapeutic tools in group care settings and deserve further development and empirical investigation to determine their effectiveness in improving mental health outcomes.

On Cherry-Picking ... or Trying to Have One’s Cake and Eating It: past principles and practice in the pursuit of an alternative to [full] EU membership

With the United Kingdom’s continued membership of the EU being increasingly questioned and the Prime Minister, David Cameron, committed to 're-negotiate’ the terms of membership, consideration is being given to what forms alternatives to [full] membership may take. While much current discussion focuses on the advantages and disadvantages of particular existing arrangements (e.g. European Economic Area, Swiss bilateralism), this paper examines the broader principles and practices that have to date underpinned – and undermined – EU’s attempts to develop alternatives to [full] EU membership. Drawing on an analysis of the evolution of association as an alternative to membership, the paper assesses the principled, practical and political limitations the EU faces – and imposes on itself – in offering an acceptable balance of rights and obligations to states not wishing to assume the mantle of full membership. In its assessment the paper considers various proposed models of affiliate and associate membership. It also situates consideration of the UK case in the broader context of the EU’s relations with other European non-member states for which membership may not be achievable and for which alternatives to membership (e.g. a form of privileged partnership) have been proposed. In doing so, the paper reflects on the precedent-setting consequences of any arrangement that the EU might reach with any state re-negotiating membership or withdrawing.

Using postal questionnaires to evaluate physical activity and diet behaviour change: case study exploring implications of valid responder characteristics in interpreting intervention outcomes.

Background: Patient reported outcome measures (PROMs) are used to evaluate lifestyle interventions but littleis known about differences between patients returning valid and invalid responses, or of potential for bias inevaluations. We aimed to examine the characteristics of patients who returned valid responses to lifestylequestionnaires compared to those whose responses were invalid for evaluating lifestyle change. 
Methods: We conducted a secondary data analysis from the SPHERE Study, a trial of an intervention to improveoutcomes for patients with coronary heart disease in primary care. Postal questionnaires were used to assessphysical activity (Godin) and diet (DINE) among study participants at baseline and 18 month follow-up. Three binaryresponse variables were generated for analysis: (1) valid Godin score; (2) valid DINE Fibre score; and (3) validDINE Total Fat score. Multivariate analysis comprised generalised estimating equation regression to examine theassociation of patients’ characteristics with their return of valid responses at both timepoints. 
Results: Overall, 92.1% of participants (832/903) returned questionnaires at both baseline and 18 months. Relativelyfewer valid Godin scores were returned by those who left school aged <15 years (36.5%) than aged 18 and over(50.5%), manual workers (39.5%) than non-manual (49.5%) and those with an elevated cholesterol (>5 mmol)(34.7%) than those with a lower cholesterol (44.4%) but multivariate analysis identified that only school leaving age(p = 0.047) was of statistical significance.Relatively fewer valid DINE scores were returned by manual than non-manual workers (fibre: 80.8% v 86.8%;fat: 71.2% v 80.0%), smokers (fibre: 72.6% v 84.7%; fat: 67.5% v 76.9%), patients with diabetes (fibre: 75.9% v 82.9%;fat: 66.9% v 75.8%) and those with cholesterol >5 mmol (fat: 68.2% v 76.2%) but multivariate analysis showedstatistical significance only for smoking (fibre: p = 0.013; fat: p = 0.045), diabetes (fibre: p = 0.039; fat: p = 0.047), andcholesterol (fat: p = 0.039). 
Conclusions: Our findings illustrate the importance of detailed reporting of research methods, with clearinformation about response rates, respondents and valid outcome data. Outcome measures which are relevant to astudy population should be chosen carefully. The impact of methods of outcome measurement and valid responserates in evaluating healthcare requires further study.

Minimal intervention dentistry and older patients part 2: minimally invasive operative interventions

As described in the first paper of this two part series, the expansion of our older population and the concomitant reduction in levels of edentulism will result in an increase in the number of patients presenting in general practice with complex restorative challenges. The application of the concepts of minimal intervention dentistry and minimally invasive operative techniques may offer a powerful armamentarium to the general dentist to provide ethical and conservative treatment to older patients.

Clinical Relevance: When it is unavoidable, operative intervention should be as minimally invasive as practicable in older patients to preserve the longevity of their natural dentition.

Subjective impact of minimally invasive dentistry in the oral health of older patients

OBJECTIVES: The aim of this study was to investigate if a minimally invasive oral health package with the use of atraumatic restorative treatment (ART) or a conventional restorative technique (CT) would result in any perceived benefit from the patients' perspective and if there would be any difference between the two treatment groups.

MATERIALS AND METHODS: In this randomised clinical trial, 99 independently living older adults (65-90 years) with carious lesions were randomly allocated to receive either ART or conventional restorations using minimally invasive/intervention dentistry (MID) principles. Patients completed an Oral Health Impact Profile (OHIP)-14 questionnaire before and 2 months after treatment. They were also asked to complete a global transition question about their oral health after treatment.

RESULTS: At baseline, the mean OHIP-14 scores recorded were 7.34 (ART) and 7.44 (CT). Two months after treatment intervention, 90 patients answered the OHIP-14 and the mean scores were 7.23 (not significant (n.s.)) and 10.38 (n.s.) for the ART and CT groups, respectively. Overall, 75.5 % of patients stated that their oral health was better compared to the beginning of treatment.

CONCLUSIONS: Although not shown by the OHIP-14, patients perceived an improvement in their overall oral status after treatment, as demonstrated by the global transition ratings in both groups.

CLINICAL RELEVANCE: Dental treatment using minimally invasive techniques might be a good alternative to treat older individuals, and it can improve their oral health both objectively and subjectively.

Minimal intervention dentistry and older patients Part 1: Risk assessment and caries prevention

Ten million people in the UK today are aged over 65. The latest projections estimate that there will be 5 1/2 million more people aged 65 and older in the next 20 years. This projected pattern of population ageing will have profound consequences for dentistry. Minimal intervention dentistry (MID) is a modern evidence-based approach to caries management in dentate patients that uses the 'medical model' whereby disease is controlled by the 'oral physician'. This approach offers considerable benefits over conventional dentistry for older patients. It encourages patients to be responsible for their oral health through the provision of both knowledge and motivation. MID encompasses risk assessment for dental disease, early detection and control of disease processes, and minimally invasive treatment. 

Clinical Relevance: Risk assessment tools can aid the general dental practitioner and the patient to develop a suitable caries prevention programme for that individual and reduce the need for future operative intervention.