Effective interventions: 25 years outside the mainstream

25 years ago when the Durham conferences were in full swing, I presented results of investigations on language and behaviour in autism. I tentatively proposed that early language in autism might tell us about the cognitive skills of people with ASD and the behaviour might lead to greater understanding of which brain systems might be affected. In this presentation, I will update these topics and present a summary of other work I have been involved with in attempting to improve the lives of people with autism and their families. Data on three people with autism at the early stages of speech development showed an unusual pattern of learning colour and number names early. One possibility was that this skill represented a sign of weak central coherence – they only attended to one dimension. Colleagues of mine were equally puzzled so we tried to find out if my results could be replicated – they were not (see Schafer, Williams & Smith, 2014). Instead we found this pattern was also seen in Down Syndrome, but that early vocabulary in autism was associated with low Colorado Meaningfulness at least in comprehension. The Colorado Meaningfulness of a word is a measure of how many words can be associated with it and often involve extensive use of context. Our data suggest that the number of contexts in which a particular word can appear has a role in determining vocabulary in ASD which is consistent with the weak central coherence theory of autism. In the course of this work I also came across a group of young people with autism who appeared to have a written vocabulary but not a spoken one. It seems possible that print might be a medium of communication when speech is not. Repetitive behaviour in autism remains a mystery. We can use functional analysis to determine why the behaviour occurs, but a worryingly large percentage of behaviours are described as being internally driven or sensory reinforced. What does that mean in terms of brain activity – could it be system analogous to epilepsy, where brain activity becomes inappropriately synchronised? At the moment I cannot claim to have solved this problem, but if sensation is a driver then sensory interventions should make a difference. Data from a recent study will be presented to suggest that for some individuals this is the case. Social behaviour remains the key however, and it remains to be seen whether it is possible for social behaviour to be aided. One route that has potential is direct teaching of skills through drama and working with others who do not have social difficulties of the same type. The picture is complicated by changes in social skills with age and experience, but the failure of people with ASD to interact when in settings of social contact is little researched.

Interventions in social networks: impact on mood and network dynamics

Results from two studies on longitudinal friendship networks are presented, exploring the impact of a gratitude intervention on positive and negative affect dynamics in a social network. The gratitude intervention had been previously shown to increase positive affect and decrease negative affect in an individual but dynamic group effects have not been considered. In the first study the intervention was administered to the whole network. In the second study two social networks are considered and in each only a subset of individuals, initially low/high in negative affect respectively received the intervention as `agents of change'. Data was analyzed using stochastic actor based modelling techniques to identify resulting network changes, impact on positive and negative affect and potential contagion of mood within the group. The first study found a group level increase in positive and a decrease in negative affect. Homophily was detected with regard to positive and negative affect but no evidence of contagion was found. The network itself became more volatile along with a fall in rate of change of negative affect. Centrality measures indicated that the best broadcasters were the individuals with the least negative affect levels at the beginning of the study. In the second study, the positive and negative affect levels for the whole group depended on the initial levels of negative affect of the intervention recipients. There was evidence of positive affect contagion in the group where intervention recipients had low initial level of negative affect and contagion in negative affect for the group where recipients had initially high level of negative affect.

Hallucinations as a trauma-based memory: implications for psychological interventions

The relationship between hallucinations and life events is a topic of significant clinical importance. This review discusses the extent to which auditory and visual hallucinations may be directly related to traumatic events. Evidence suggests that intrusive images occur frequently within individuals who also report hallucinatory experiences. However, there has been limited research specifically investigating the extent to which hallucinations are the re-experiencing of a traumatic event. Our current theoretical understanding of these relationships, along with methodological difficulties associated with research in this area, are considered. Recent clinical studies, which adopt interventions aimed at the symptoms of post-traumatic stress disorder in people diagnosed with a psychotic disorder, are reviewed. There is a need for the development of evidence-based interventions in this area.

Internal and External Time Conflicts in Adolescents: Sleep Characteristics and Interventions

Daytime fatigue and lack of sleep seem to increase throughout adolescent years. Several environmental, psychological, and biological factors have been associated with the development of sleep across adolescence. The aim of the present article is to summarize these factors and to give examples of various outcomes in sleep patterns among adolescents studied in different cultural settings. It is obvious from earlier work that many adolescents have displaced circadian rhythms and lack of adaptation to school hours due to an early school start or additional burdens for work. Several interventions have aimed to help the adaptation process by supporting sleep processes and changing scheduling, in this way promoting classroom alertness. In summary, adolescents worldwide shorten their sleep due to schoolwork hours and additional work, especially by disturbing their sleep due to circadian misalignment.

Barriers to interventions aimed at promoting the health of health care workers in Brazil

Objective. To search the literature for circumstances that impede injury and disease prevention and other activities intended to improve the health of the health care worker. Methods. The SciELO database was searched for articles published in 1967-2008. This was supplemented by a PubMed search for the period 1950-2008. The following key words were used to identify articles in English, Portuguese, and Spanish: work, health personnel, occupational, risks, diseases, ergonomics, work ability, quality of life, organization, accidents, work conditions, intervention, and administration. Articles on injury and disease prevention and occupational health in a health care setting in Latin America were selected, along with articles focused on health promotion in the health sector. Results. The following shortcomings were identified: activities lacked a sound theoretical foundation and were not integrated with the health services management; a failure to evaluate the effectiveness of the activity; health surveillance focused solely on a specific disease or injury; management not committed to the proposed activity; miscommunication; inability of workers to participate, or control the work environment; and, programs or efforts that were limited to changing the workers` behaviors. Conclusions. The literature shows that all the barriers identified by this study affect both the health care workers` health as well as their productivity.

A systematic review of triage-related interventions to improve patient flow in emergency departments

Background Overcrowding in emergency departments is a worldwide problem. A systematic literature review was undertaken to scientifically explore which interventions improve patient flow in emergency departments. Methods A systematic literature search for flow processes in emergency departments was followed by assessment of relevance and methodological quality of each individual study fulfilling the inclusion criteria. Studies were excluded if they did not present data on waiting time, length of stay, patients leaving the emergency department without being seen or other flow parameters based on a nonselected material of patients. Only studies with a control group, either in a randomized controlled trial or in an observational study with historical controls, were included. For each intervention, the level of scientific evidence was rated according to the GRADE system, launched by a WHO-supported working group. Results The interventions were grouped into streaming, fast track, team triage, point-of-care testing (performing laboratory analysis in the emergency department), and nurse-requested x-ray. Thirty-three studies, including over 800,000 patients in total, were included. Scientific evidence on the effect of fast track on waiting time, length of stay, and left without being seen was moderately strong. The effect of team triage on left without being seen was relatively strong, but the evidence for all other interventions was limited or insufficient. Conclusions Introducing fast track for patients with less severe symptoms results in shorter waiting time, shorter length of stay, and fewer patients leaving without being seen. Team triage, with a physician in the team, will probably result in shorter waiting time and shorter length of stay and most likely in fewer patients leaving without being seen. There is only limited scientific evidence that streaming of patients into different tracks, performing laboratory analysis in the emergency department or having nurses to request certain x-rays results in shorter waiting time and length of stay.

How single is ‘single’ : some pragmatic reflections on single versus multifaceted interventions to facilitate implementation

An earlier overview of systematic reviews and a subsequent editorial on single-component versus multifaceted interventions to promote knowledge translation (KT) highlight complex issues in implementation science. In this supplemented commentary, further aspects are in focus; we propose examples from (KT) studies probing the issue of single interventions. A main point is that defining what is a single and what is a multifaceted intervention can be ambiguous, depending on how the intervention is conceived. Further, we suggest additional perspectives in terms of strategies to facilitate implementation. More specifically, we argue for a need to depict not only what activities are done in implementation interventions, but to unpack functions in particular contexts, in order to support the progress of implementation science.

Making Energy Interventions more Effective : Situation, Interaction, and Precondition

A main purpose of this paper is to propose to policy makers, building professionals, and other non-social scientists a way to make energy interventions more culturally informed and, thereby, more effective. The case study on house purchasers gives an ample illustration of the richer results that can be achieved by paying attention to three aspects of energy efficiency initiatives: the contexts and situations of choice in each particular case, the interaction among relevant social actors, and the culture-specific preconditions for choice. Research on how purchasers of new pre-fabricated houses in Sweden choose their heating system show how such decisions tend to fall between two stools. Furthermore, the organizational structure of housing companies frames house purchasers' decision making. An important result is that energy saving or conversion measures must be promoted at an early stage amongst those who plan and construct buildings (rather than later amongst dwellers and energy end users).

Identification and estimation of interventions using changes in inequality measures

This paper presents semiparametric estimators of changes in inequality measures of a dependent variable distribution taking into account the possible changes on the distributions of covariates. When we do not impose parametric assumptions on the conditional distribution of the dependent variable given covariates, this problem becomes equivalent to estimation of distributional impacts of interventions (treatment) when selection to the program is based on observable characteristics. The distributional impacts of a treatment will be calculated as differences in inequality measures of the potential outcomes of receiving and not receiving the treatment. These differences are called here Inequality Treatment Effects (ITE). The estimation procedure involves a first non-parametric step in which the probability of receiving treatment given covariates, the propensity-score, is estimated. Using the inverse probability weighting method to estimate parameters of the marginal distribution of potential outcomes, in the second step weighted sample versions of inequality measures are computed. Root-N consistency, asymptotic normality and semiparametric efficiency are shown for the semiparametric estimators proposed. A Monte Carlo exercise is performed to investigate the behavior in finite samples of the estimator derived in the paper. We also apply our method to the evaluation of a job training program.

Domestic violence in Brazil: social problems and legislative interventions

Recent statistical data confirms that domestic violence is a structural problem of exceptional gravity. We analyze the frequent legislative changes in Brazil since 2000 as a result of social pressure for protection of abused women. Only the Law 11.340 of 2006 was well received by lawyers, judges and the public opinion. We present the innovations and peculiarities of this statute and the allegations on unconstitutionality. We discuss cases of judicial review of this law and reject the arguments of unconstitutionality. That notwithstanding, we argue that penalization decisions is the wrong way from a criminological point of view because they do not take into consideration the desires and needs of the victims.