Formal Outcome Measures Research Articles

Non-pharmacological interventions for cognitive impairment in older adults with heart failure: A systematic review

BackgroundCognitive impairment is a prevalent issue among older adults with heart failure, and non-pharmacological approaches are recommended as the first line of treatment. However, it remains unclear which non-pharmacological interventions are the most effective for achieving optimal cognitive and physical outcomes. The aim of this study is to summarize the available evidence on the impact of non-pharmacological interventions for optimizing cognitive function in older adults with HF. MethodsA systematic research was carried out across multiple databases including PubMed, Embase, Scopus, Web of Science, PsycINFO, Cochrane Library, Chinese National Knowledge Infrastructure Database, and Wanfang Database up until May 2022. Randomized controlled trials that focused on non-pharmacological interventions for older adults with heart failure and cognitive impairment, and evaluated the impact on cognitive function were targeted. The risk bias of the selected articles was analyzed following the Cochrane handbook. Two independent reviewers were responsible for selecting the studies, extracting the data, and assessing their quality. The results were reported in a narrative format. ResultsA total of 11 studies, which involved 1,287 patients, were reviewed and showed an acceptable risk of bias. These studies evaluated various cognitive domains, including global cognition, delayed recall memory, working memory, and verbal memory. Non-pharmacological interventions that included cognitive intervention, cognitive training combined with exercise, exercise training, and self-care management, were shown to have a positive impact on cognitive function, physical performance, and depression levels in older adults with heart failure. One study explored the effects of electrical muscle stimulation therapy, but no significant improvement in cognitive abilities was observed. ConclusionThe available evidence for the effectiveness of non-pharmacological interventions for cognitive impairment in older adults with heart failure is limited, and further research with formal outcome measures and longer follow-up periods is necessary to provide more informed recommendations.

Offline Digital Education for Post Registration Health Professions;systematic review by the Digital Health Education Collaboration

A substantial body of literature exists on the use of digital education for online learning. One question that has not been fully researched is whether such programs work offline as well as online. This systematic review by the Digital Health Education Collaboration explores this question through 17 observational studies on post-registration health professions learners (N= 14,794) in the US, Canada, Puerto Rico, Germany and Australia. The strength of this research was its use of a meta-analysis; however, it is limited to one type of learner and there were no formal outcome measures examined nor any assessment of embodied cognition outcomes. finally designs the College English blended teaching model based on the data mining algorithm, so as to realize the College English online and offline blended teaching, The experiment shows that the method designed in this paper can effectively improve the reading ability of College English, and has certain application value.

A Preliminary Investigation on the Effects of Atenolol for Treating Symptoms of Anxiety.

Anxiety disorders are among the most commonly diagnosed of psychiatric disorders. Many symptoms of posttraumatic stress disorder are also anxiety-related. Traditional medications used to treat these disorders, such as antidepressants and benzodiazepines, are often ineffective, not well-tolerated, and can be habit forming. An alternative agent is, therefore, needed. Beta-blockers are one class of medication with potential to treat anxiety-related disorders; however, current evidence remains limited and requires further characterization. To this end, this retrospective study aims to present a novel preliminary report on the use of the beta-blocker, atenolol, to potentially treat anxiety-related disorders. Ninety-two patients were identified from outpatient military mental health clinics in Okinawa, Japan, who had received atenolol for mental health-related symptoms. Primary measures collected were the rates of patient-reported (1) general beneficial/positive effect of atenolol, (2) adverse effects from atenolol, and (3) preference of atenolol to propranolol. Data were collected from patients who were given binary response options to report their perceived experiences for each primary measure. This study was approved by the Naval Medical Center San Diego Institutional Review Board. The results showed 86% of patients reporting a positive effect and continuing to take atenolol, including 87% with a diagnosis of posttraumatic stress disorder, 100% with diagnosis of other specified trauma- and stressor-related disorder, and 81% diagnosed with anxiety disorders. In total, 90% of patients denied adverse effects or found the adverse effects tolerable. Additionally, 100% of patients who had previously taken propranolol for anxiety reported that they preferred atenolol. The present preliminary observational data suggests that atenolol may be well-tolerated and effective among persons with anxiety disorders. These data also suggest that atenolol may be more effective and better tolerated than propranolol, which is the most commonly prescribed beta-blocker for these conditions; however, more rigorously controlled empirical studies are needed to further substantiate this claim. Despite an overwhelmingly high rate of positive reports from patients' self-evaluations of atenolol treatment for anxiety-related disorders, this early investigation was not placebo-controlled nor double-blinded, and formal outcome measures were not assessed due to a lack of availability. More detailed examinations are needed to further determine whether atenolol is a viable alternative or augmenting agent to propranolol, benzodiazepines, and antidepressants for anxiety disorders and trauma-related disorders.

Transcranial direct current stimulation (tDCS) for improving aphasia in adults with aphasia after stroke.

Stroke is one of the leading causes of disability worldwide and aphasia among survivors is common. Current speech and language therapy (SLT) strategies have only limited effectiveness in improving aphasia. A possible adjunct to SLT for improving SLT outcomes might be non-invasive brain stimulation by transcranial direct current stimulation (tDCS) to modulate cortical excitability and hence to improve aphasia. To assess the effects of tDCS for improving aphasia in people who have had a stroke. We searched the Cochrane Stroke Group Trials Register (June 2018), CENTRAL (Cochrane Library, June 2018), MEDLINE (1948 to June 2018), Embase (1980 to June 2018), CINAHL (1982 to June 2018), AMED (1985 to June 2018), Science Citation Index (1899 to June 2018), and seven additional databases. We also searched trial registers and reference lists, handsearched conference proceedings and contacted authors and equipment manufacturers. We included only randomised controlled trials (RCTs) and randomised controlled cross-over trials (from which we only analysed the first period as a parallel group design) comparing tDCS versus control in adults with aphasia due to stroke. Two review authors independently assessed trial quality and risk of bias, and extracted data. If necessary, we contacted study authors for additional information. We collected information on dropouts and adverse events from the trials. We included 21 trials involving 421 participants in the qualitative synthesis. Three studies with 112 participants used formal outcome measures for our primary outcome measure of functional communication - that is, measuring aphasia in a real-life communicative setting. There was no evidence of an effect (standardised mean difference (SMD) 0.17, 95% confidence interval (CI) -0.20 to 0.55; P = 0.37; I² = 0%; low quality of evidence; inverse variance method with random-effects model; higher SMD reflecting benefit from tDCS; moderate quality of evidence). At follow-up, there also was no evidence of an effect (SMD 0.14, 95% CI -0.31 to 0.58; P = 0.55; 80 participants ; 2 studies; I² = 0%; very low quality of evidence; higher SMD reflecting benefit from tDCS; moderate quality of evidence).For our secondary outcome measure, accuracy in naming nouns at the end of intervention, there was evidence of an effect (SMD 0.42, 95% CI 0.19 to 0.66; P = 0.0005; I² = 0%; 298 participants; 11 studies; inverse variance method with random-effects model; higher SMD reflecting benefit from tDCS; moderate quality of evidence). There was an effect for the accuracy in naming nouns at follow-up (SMD 0.87, 95% CI 0.25 to 1.48; P = 0.006; 80 participants; 2 studies; I² = 32%; low quality of evidence); however the results were not statistically significant in our sensitivity analysis regarding the assumptions of the underlying correlation coefficient for imputing missing standard deviations of change scores. There was no evidence of an effect regarding accuracy in naming verbs post intervention (SMD 0.19, 95% CI -0.68 to 1.06; P = 0.67; I² = 0%; 21 participants; 3 studies; very low quality of evidence). We found no studies examining the effect of tDCS on cognition in people with aphasia after stroke. We did not find reported serious adverse events and the proportion of dropouts and adverse events was comparable between groups (odds ratio (OR) 0.54, 95% CI 0.21 to 1.37; P = 0.19; I² = 0%; Mantel-Haenszel method with random-effects model; 345 participants; 15 studies; low quality of evidence). Currently there is no evidence of the effectiveness of tDCS (anodal tDCS, cathodal tDCS and Dual-tDCS) versus control (sham tDCS) for improving functional communication in people with aphasia after stroke (low quality of evidence). However, there is limited evidence that tDCS may improve naming performance in naming nouns (moderate quality of evidence), but not verbs (very low quality of evidence) at the end of the intervention period and possibly also at follow-up. Further methodologically rigorous RCTs with adequate sample size calculation are needed in this area to determine the effectiveness of this intervention. Data on functional communication and on adverse events should routinely be collected and presented in further publications as well as data at follow-up. Further study on the relationship between language/aphasia and cognition may be required, and improved cognitive assessments for patients with aphasia developed, prior to the use of tDCS to directly target cognition in aphasia. Authors should state total values at post-intervention as well as their corresponding change scores with standard deviations.

Extreme lateral interbody fusion (XLIF) as a treatment for acute spondylodiscitis: Leeds spinal unit experience

Extreme lateral interbody fusion (XLIF) is a minimally invasive lateral trans-psoas approach to the thoraco-lumbar spine that enables surgical debridement of the disc space and facilitates fusion. Previous reports are limited to case series, which have no outcomes measuring improvement. We aim to determine the effectiveness of XLIF in the treatment of patients with spondylodiscitis. We performed a cohort study over four years (2008–2011). Patients were treated with XLIF if they met our selection criteria - symptoms suggestive of discitis with consistent imaging and intractable back pain making patients bedbound. Patients were excluded if medically unfit for surgery. Pre and post-operative VAS and ODI scores were used as formal outcome measures. 14 patients were included and at 12 months, median VAS and ODI scores had improved 4.0 (95% CI, 1.9–6.5) (p = 0.005) and 37.0% (95% CI, 10.7–53.7) (p = 0.015) respectively. All patients with available imaging showed evidence of fusion. Patients typically received 6–8 weeks of antibiotics and all showed normalisation of inflammatory markers. At 5 year follow-up, median VAS and ODI were still improved at 3.0 (95% CI, 1.7–4.4) (p = 0.01) and 40% (95% CI, 10–52) (p = 0.028) respectively. The median length of inpatient stay was 10 days (range 4–40 days). This is the first study to demonstrate that the XLIF technique can significantly improve pain in discitis patients using validated formal outcome measurements. This technique could therefore potentially be used to reduce pain in patients with discitis, help them to mobilise earlier and reduce the duration of their hospital stay.

19.4 CAT IN FIRST-EPISODE PSYCHOSIS: FEASIBILITY, ACCEPTABILITY AND POTENTIAL TO ENHANCE VOCATIONAL RECOVERY

BackgroundCognitive and functioning impairments are present early in the course of psychotic disorder and remain one of the greatest treatment challenges in this population. While Cognitive Adaptation Training (CAT) is found to improve a range of outcomes in chronic schizophrenia, it has received limited investigation in first-episode psychosis (FEP). CAT may be particularly useful for addressing vocational recovery in FEP because the cognitive impairments experienced by individuals with FEP predict poorer vocational outcomes and impede the effectiveness of vocational interventions such as supported employment. The aim of this presentation is to present the findings of a pilot study investigating the feasibility and acceptability of CAT in young people with FEP and to describe the clinical considerations and adaptations required when delivering CAT with this population. Preliminary findings on the potential value of CAT in improving vocational outcomes in FEP will also be presented.MethodsThis was a single-arm feasibility study of CAT conducted at the Early Psychosis Prevention and Intervention Centre (EPPIC), Melbourne, Australia. Five FEP participants received 9 months of manually-guided CAT. A range of feasibility and acceptability measures were recorded, including participant and case manager satisfaction ratings. Participants’ goals, functional needs and clinical observations and adaptations were also recorded. Formal measures of functioning, quality of life and motivation were independently administered pre- and post-intervention.ResultsAll participants completed the CAT intervention and session attendance rates were very high (95.3%). Participants and their case managers indicated strong satisfaction with CAT as indicated by overall positive mean ratings on the satisfaction items. CAT did not negatively affect existing case management, with case managers reporting that it enhanced their treatment. Vocational recovery (education, employment) was found to be a primary functional goal of most participants. Accordingly, the CAT intervention had a strong focus on vocational functioning, including functional domains that are requisite for successful work or educational outcomes, including organisation and planning, transportation and activities of daily living. Being mindful of factors that may be common in young FEP patients included cognitive heterogeneity, family involvement, flexibility in compensatory and environmental supports used, and the experience of stigma. There were mean improvements from baseline to post-intervention on most formal outcome measures, with the largest effects in global functioning, planning and organisation, and quality of life.DiscussionThis study provides encouraging preliminary evidence that CAT is a highly feasible and acceptable intervention in FEP, which may be easily integrated within existing early intervention services. Vocational recovery is important to young people with FEP. CAT is an intervention that appears well suited to addressing this need. The effectiveness of CAT in improving functional outcomes, particularly vocational recovery in FEP warrants further investigation in a larger trial.

Myofascial Release and Muscle Retraining for Dropped Head Syndrome Attributed to Radiation Fibrosis in Hodgkin Lymphoma: A Case Series

Background and Purpose: This article reviews the current knowledge base of dropped head syndrome and presents the case histories of 7 patients with a diagnosis of this condition at the Royal Hallamshire Hospital, Sheffield, through the Late Effects Clinic. All patients were referred for physiotherapy, and the assessment findings and subsequent treatment provided are discussed in detail. Case Description: Seven patients who were consecutively referred to physiotherapy and presented with signs and symptoms of suspected dropped head syndrome following previous treatment with mantle radiotherapy for Hodgkin lymphoma are discussed. Physiotherapy was delivered at various time intervals and duration on a one-to-one basis. Interventions were delivered to restore soft tissue length, rehabilitate proprioception, increase neck stabilizer strength, and retraining of muscles through range both locally and distally. Outcomes: All 7 patients reported subjective improvements in pain and function, with objective improvements in local and distal posture, tolerance to maintain head on neck position, and ability to grade through range neck movement locally. No formal outcome measures were used, as this is a retrospective report. Conclusion: Physiotherapy can offer short-term subjective and objective improvements in head on neck posture and control and effect more distal postural changes. Longer-term maintenance of improvements gained has yet to be determined. The most effective time point posttreatment for therapy intervention requires further research as does the type of physiotherapy intervention to be offered.

Correcting Psychotherapists' Blindsidedness: Formal Feedback as a Means of Overcoming the Natural Limitations of Therapists

Monitoring of client progress in psychological therapy using formal outcome measures at each session has been shown to increase the effectiveness of treatment. It seems likely that this 'feedback' effect is achieved by enabling therapists to identify clients at risk of treatment failure so that therapists can pay greater attention to client difficulties, which may be hindering therapeutic work. To date, little attention has been given to understanding relevant mechanisms of formal feedback in psychological therapy. In order to understand and maximize the benefits of feedback, it is essential to explore potential mechanisms contributing to this effect. Research in social psychology may help to explain how feedback works. Findings on cognitive biases in the field of social psychology are explored and linked to preliminary findings in the field of psychotherapy research. Research on cognitive biases and expertise is congruent with indications that clinical prediction in psychotherapy is unreliable and that it may be difficult for clinicians to detect errors in their judgement as a result of a lack of clear corrective feedback. This problem is linked to the fact that clinical outcomes occur in a complex 'noisy' environment where prediction is inherently difficult. Formal feedback may derive its benefits from its ability to help correct naturally occurring biases in therapists' assessment of their work. If these biases are seen as normal, but often avoidable if feedback is used, this may pave the way to greater acceptance of formal feedback by clinicians and enhanced outcomes for clients. The use of formal feedback tools can help therapists overcome inevitable limitations in their ability to predict poor response to treatment, enhancing the likelihood of detecting and resolving client difficulties in therapy.

Monitoring improvement in health during homeopathic intervention. Development of an assessment tool based on Hering’s Law of Cure: the Hering’s Law Assessment Tool (HELAT)

Hering's 'Law of Cure' is considered important in homeopathy and thought to predict a positive outcome to treatment. No formal outcome measures are currently available to monitor response to homeopathic treatment on the basis of these assumptions. We describe a simple assessment tool, the Hering's Law Assessment Tool (HELAT) to identify and differentiate patient responses to homeopathic treatment as corresponding to Hering's Law from other symptomatic responses. We describe the development of the tool and assess its face, content and predictive validity. The HELAT was initially developed through literature review, discussion between homeopaths and clinical experience. In phase one, the tool was reviewed by three experienced homeopaths to assess face and content validity. In phase two, we tested its predictive validity by hypothesizing that the HELAT total score may predict changes in a clinical response (using standard validated rheumatological outcome, the American College of Rheumatology (ACR)20%) in 32 patients with rheumatoid arthritis receiving homeopathic intervention over 24 weeks as part of a clinical trial. The HELAT was piloted and changed to improve face and content validity and the final version was then employed for phase two as a predictor of outcome. HELAT total score predicted patient's clinical response (ACR20) [B = 1.142, SE = 0.462, P = 0.013] which was independent of practitioner assessing the patients treatment response [B = 1.04, SE = 1.01, P = 0.302]. The initial data suggests that the HELAT may hold promise for a potential clinical and research outcome measure in homeopathy. Further work is now needed to formally assess its reliability and validity for potential use in clinical practice and trials.

Quality of life and the outcome of established rheumatoid arthritis

Rheumatoid arthritis (RA) is a long-term condition causing joint pain and swelling and sometimes systemic involvement. The aims of treatment are, first, to reduce the impact the disease has on a patient and, second, to halt progression of disease. The advent of intensive therapy, including biologics, has led to a major improvement in outcome. To assess treatment impact, formal outcome measures have been developed. Traditionally, these focussed on the clinical aspects such as disease activity and joint damage. More recently, there has been an increased focus on patient-related outcome measures including quality-of-life measures. These enable illness evaluation from patients' perspectives, examination of care quality and comparison of the effectiveness and cost-effectiveness of treatment. This article examines advantages and disadvantages of the various outcome measures which are generally used in RA, with a focus on quality of life and patient-related measures.

An occupational therapy programme in a religious community in South Africa: A Historical Narrative

The purpose of this paper was to describe an occupational therapy programme that addressed the needs of younger nuns as they faced the difficulties of caring for older nuns in a Dominican old-age home in South Africa. Weekly occupational therapy group sessions with the younger sisters over a 1-year period enabled them to cope with an elderly population who were struggling to adapt to life in an old-age home. Activity groups and individual sessions were run concurrently with the older sisters. Aspects addressed included: dealing with loss, exploring meaningful activity, communication, healthy lifestyles, community involvement and life review. No formal outcome measures were used. Informal evidence of the effectiveness of the programme is the occupationally healthy community observed 20 years later. The younger enablers are now the care receivers and play an integral part in sustaining the programme. Although the Dominican community has specific needs and practices, there is a parallel to other groups of older adults adjusting to a care setting. This programme can serve as a model to facilitate the quality of life of caregivers and residents. The programme outcomes support the principles of occupational science by demonstrating the importance of engaging in meaningful activities to maintain health and well-being.

Group motivational enhancement therapy as an adjunct to inpatient treatment for eating disorders: a preliminary study

Difficulties in fostering eating disorder (ED) patients' motivations to overcome their illness are widely considered to be a major hurdle in the course of successful treatment. However, no previous study has assessed the use of interventions specifically designed to target poor motivation amongst patients with illnesses that are severe enough to warrant hospitalisation. A brief Motivational Enhancement Therapy (MET) group programme for inpatient ED sufferers was developed and evaluated. Forty two consecutive inpatients were sequentially allocated to treatment groups. Twenty three inpatients completed a four session MET group programme in addition to routine hospital care. A control group of 19 participants completed treatment as usual (TAU). Despite an absence of significant differences between the MET and the TAU groups on the overall formal outcome measures, there were nevertheless differences between the groups. Specifically, the MET groups appeared to foster longer term motivation and engagement, and to promote treatment continuation. The results tentatively suggest that MET could be valuable for the treatment of inpatient eating disorder patients and further research is warranted.

The use of outcome scores in surgery of the shoulder

The pursuit of ‘best practice’, health economic planning, the increasing awareness and expectations of patients, pressure from politicians and the media, and the emergence of league tables for surgeons are some of the reasons why orthopaedic surgeons are encouraged to adopt evidence-based

Developing and Implementing Lifestyle Management Programs© with People with Multiple Sclerosis

SUMMARYThis paper describes the development and use of Lifestyle Management Programs© (LMPs) by occupational therapists at the Multiple Sclerosis Society of New South Wales, Australia. A case study is used to demonstrate how the program is applied in an individual situation. LMPs are used with people with MS, or their support people, to enable management of the impact of fluctuating and interactive physical, sensory and cognitive symptoms. LMPs are flexible and adaptable systems, allowing integration of information and strategies for managing symptoms. LMPs assist clients to sustain meaningful activities and life roles. Subjective client feedback supports the effectiveness of the programs in meeting specific individual goals. Formal outcome measures are being explored.

Is training in psychosocial interventions worthwhile? Report of a psychosocial intervention trainee follow-up study

A follow-up study of psychosocial intervention (PSI) trainees from the Sheffield and Maudsley training centres was undertaken in three stages. In Stage 1, 141 students, at two PSI training centres, were sent a simple postal questionnaire to elicit career trajectory following PSI training. A response rate of 82% was achieved. The sub-group, who had been trained and who still engaged in clinical practice were identified and followed-up in more detail ( n=96). The effect of PSI training in a range of domains was investigated. The impact of training may not be to equip students with formal technical skills in CBT and family work. What is more likely is that trainees acquired proficiency in: working effectively using a case management model; conveying ‘therapeutic optimism’; enabling users to meet their own goals and helping them to develop better coping strategies; using ‘stress vulnerability’ and formal outcome measures as means of structuring this approach. The secondary aim of the study was to identify and prioritise the barriers that impede the effective implementation of PSI skills in routine service settings. For the second phase of the survey the response rate was again 82%. This group's service managers were identified and surveyed for the same information and 59% responded. The aim was to gather information about implementation issues from both the clinical and service perspectives. The results of the survey indicate that PSI training has a positive impact on the development of services for people with serious mental health problems although there are serious organisational hurdles for managers, trainees and organisations to overcome if PSI skills are to be properly implemented. Key factors that impact upon faithful implementation are related to resource issues (caseload size), organisational factors (the existence of an implementation plan and training strategy), and the extent to which the trainee's team is supportive.

ENDOCRINE PBL IN THE YEAR 2000

The Southern Illinois University School of Medicine (SIU-SOM) has utilized problem-based learning (PBL) in its curriculum since 1981, when Dr. Howard Barrows joined the faculty. From 1989 to 2000, SIU-SOM implemented two parallel curricula for the basic science years (years I and II), one curriculum being a problem-based learning curriculum (PBLC). An executive decision to design and implement a single curriculum, to begin in Fall 2000, fostered a review of existing pedagogy upon which to base this new curriculum: C2000. The results of this review, which considered formal outcome measures as well as internal review in consideration of the institutional mission, led to PBL becoming the predominant pedagogy for C2000, albeit with some modifications from its PBLC predecessor. C2000, then, represents the third iteration of PBL in use at SIU-SOM, and its design and rationale offer insight for the teaching of Endocrine Physiology in a PBLC.

Extrafamilial sexual abuse: treatment for child victims and their families

Objectives: To decrease the emotional distress of child victims of extrafamilial sexual abuse (ESA) and their families. To provide crisis intervention, individual and group treatment in response to an expressed need in the community. To pilot the use of group treatment for child victims of ESA under age 10. Method: This discussion describes intervention with a sample of 246 child victims, ages 2–14 years, and 323 parents who participated in the program from 1984 to 1991. This pilot project operated at a university medical facility and was located off campus in an outpatient child abuse center. Priority was given to child victims under age 7. Child victims and their families were evaluated after investigative interviews by law enforcement agencies were completed. A treatment plan was developed based on clinical assessment. Families participated in crisis counseling, individual treatment for the child victim and/or parent, Children’s Treatment Groups, Parent Support Groups, or were referred to other resources. Clinical assessment of treatment progress included weekly case review by child and parent therapists, video analysis and observation of Children’s Treatment Group sessions, consultation with parents and collateral contacts. Results: A family approach and services for parents in addition to intervention for child victims were determined to be key components in facilitating recovery. Clinical observations and client feedback showed positive outcomes for child victims and parents with crisis counseling, Children’s Treatment groups, and Parent Support Groups. The extent of intervention ranged from one session to 24 months with an average participation of 6–9 months. Follow up surveys were returned by parents for 48 child victims and results are reported. Themes, parallels in responses, and recovery factors for child victims and parents are discussed. Conclusions: The need for intervention and a community-based program was demonstrated by (1) the significant disruption in functioning that occurred for child victims of ESA and their families, (2) the risk for long term sequelae, (3) the high incidence of extrafamilial sexual abuse, and 4) the consistent, large number of requests for services. Family-centered crisis services, Children’s Treatment Groups, and Parent Support Groups can be effectively based at child advocacy centers, out patient care clinics, or other community agencies. The results of formal outcome measures and longitudinal studies is needed to determine how child victims and parents benefit from specific treatment modalities and to better guide the use of limited resources.