Intrusive Procedures Research Articles

Formal versus informal interventions for challenging behaviour in persons with intellectual disabilities.

Although effective, humane treatments exist for persons with intellectual disabilities (ID) who have challenging behaviour, little research has examined the extent to which clients receive formal, documented vs. undocumented interventions. Caregivers (of 625 persons with ID living in community and institutional residences in Ontario, Canada) were interviewed to examine the prevalence of different types of interventions. Overall, 55% of the 2506 different interventions (for 1464 target behaviours) were informal (i.e. lacking documented input from a professional, written intervention plans, and systematic evaluation). No significant differences emerged on formality of intervention across participant gender, age, level of ID, and type of residence. There were significantly more informal than formal behavioural interventions and counselling/psychotherapy, and no significant difference in the overall prevalence of formal and informal intrusive procedures. Behaviour control medications were paired more often with formal (67%) than informal interventions for dangerous behaviours. Formal interventions were associated with higher caregiver-reported estimates of behavioural improvement, higher inter-rater agreement on the descriptions of an individual client's target behaviours and interventions, and more caregiver training and supervision. The low levels of intervention accountability, training and supervision may place many clients with challenging behaviour at increased risk for ineffective and unnecessary restrictive interventions, and physical abuse. The results of this survey stimulated the government to write province-wide standards (that have yet to be implemented).

On the status of knowledge for using punishment implications for treating behavior disorders.

In this paper, we review basic and applied findings on punishment and discuss the importance of conducting further research in this area. The characteristics of responding during punishment and numerous factors that interact with basic processes are delineated in conjunction with implications for the treatment of behavior disorders in clinical populations. We conclude that further understanding of punishment processes is needed to develop a highly systematic, effective technology of behavior change, including strategies for improving the efficacy of less intrusive procedures and for successfully fading treatment.

Documentation of Changes in Modal Properties of a Concrete Box‐Girder Bridge Due to Environmental and Internal Conditions

The results of two modal tests preformed on a concrete box girder bridge are presented. The two modal tests were performed on the bridge sequentially with a 9‐month time interval between tests. This sequence of tests form the initial phase of a modal‐based level IV nondestructive damage‐evaluation process implemented to establish the rate of structural deterioration and remaining service life of the tested structure. A level IV process detects, locates, and sizes damage and determines the impact of the damage on the performance of the structure. A novel feature of the field testing is the execution of an incremental and minimally intrusive (to existing traffic flow) modal test procedure. The instrumentation, experimental test plan, and resulting modal analyses are discussed. In addition, the changes in the two modal data sets are discussed.

Mean pressures and flows in the human intracranial system as determined by mathematical simulations of a steady-state infusion test

In order to understand the fluid dynamics within the human intracranial system, the relatively small flow of extracellular fluid into, and out of, the interstitial brain tissue must be determined. Due to the magnitude of these flows, it is difficult to measure them clinically. Through a steady-state infusion simulation run on a mathematical model, values for these small flows may be calculated based on clinical data regarding the conductance of cerebrospinal fluid outflow. In this way, the mathematical model allows information to be obtained regarding these small mean flows, as well as the remaining mean flows and mean pressures throughout the Intracranial space, with minimal reliance on data from intrusive procedures. [Neurol Res 2000; 22: 809-814]

Clothing as a source of fibres within museums

This paper examines the role of visitors’ clothing as a source of fibres and dust in museums. Some idealised experiments determined the mass of fibres and dust emitted from clothing and the range of particle sizes found. In chamber studies it was possible to examine the effect of different humidity and airflow on fibre release. Image analysis was used to determine particle size from sub-micron to giant particles including clothing fibre. Clothing was a significant contributor to fibre and dust generation and at low humidity winter garments composed largely of wool was especially large. High air velocity increased particle shedding from clothing. Clean clothing typically released a third to a tenth the weight of particulate material from dirty clothing. It is possible that the fibres and dust produced indoors from visitors could be reduced by an air-shower at the entrance, but less intrusive procedures such as keeping visitors at a distance from objects may be preferable.

Aggression and the termination of “rituals”: a new variant of the escape function for challenging behavior?

Aggression and stereotyped behaviors are not uncommon among people with intellectual disabilities and they are often treated separately as operant behaviors. In this single case study, it is argued that the function of a young woman’s aggressive behavior appeared to be that of avoiding or escaping the termination of a chain of complex stereotyped behavior (or “ritual”). She became aggressive only when this chain of stereotyped behavior was terminated and the aggression appeared to extinguish when it no longer led to escape from the termination of the “ritual”. It is suggested that this is an example of a complex interaction between two behaviors and that it illustrates the need for very careful analysis of the functions of challenging behavior. Furthermore, it is proposed that the lengthening list of variables already documented as determinants of challenging behavior (provision of attention (verbal and physical), mechanical restraint, sensory or tangible events, escape from demands or from social attention, denials, escape from intrusive medical procedures, escape from task difficulty) be lengthened to include the possibility of escape from (or avoidance of) the interruption of a chain of complex stereotyped behavior or “ritual”.

Practice observed: is speculum examination on admission a necessary procedure in the management of all cases of antepartum haemorrhage?

The objective of the study was to determine the justification or otherwise of admission speculum examination in women presenting with antepartum haemorrhage and the outcome/ benefits of the practice on women with antepartum haemorrhage presenting to the delivery suite of a UK teaching hospital. Factors studied included gestational age at presentation, associated factors with the bleeding, grade of medical/ midwifery staff performing the admission speculum examination, findings on speculum examination and ultrasound scan and the overall pregnancy outcome. Of the 564 (4.9%) women who presented with antepartum haemorrhage; 521 had an admission speculum examination; 94.4% of these were by senior house officers (SHOs). The findings were a normal cervix (69%) and ectopy (21.3%). Of the women, 14.4% had recurrent bleeding and 8.5% went into preterm labour. The complications of the pregnancies, timing of delivery and management were independent of speculum examination. Admission speculum examination did not influence the management of pregnancies and the complications thereafter. These results suggest that such an intrusive procedure may not be justifiable in women presenting with antepartum haemorrhage.

Psychosocial impact of pediatric BMT on siblings.

Although bone marrow transplantation (BMT) has become standard therapy for many life-threatening disorders of childhood, there is little research on the psychosocial impact of BMT on siblings of children undergoing BMT. Such siblings face issues common to any family with a chronic illness. However, the psychological impact on the family is intensified because two family members, usually children, are subjected to intrusive medical procedures. Investigators had earlier noted that sibling donors may be at risk for behavioral problems and anxiety, while nondonors may experience ambivalent feelings of disappointment and relief. It was suggested that psychosocial stages of BMT may parallel the medical transplant process, with high levels of stress experienced pre-BMT, during hospitalization, and post-discharge. Our own group has recently conducted more systematic investigations on the psychosocial effects of BMT on donor vs nondonor siblings of surviving pediatric BMT patients. We found that sibling donors showed significantly more anxiety, lower self-esteem, and more adaptive skills in school than nondonors. Nondonors, on the other hand, showed significantly more school problems. One third of the siblings in each group reported a moderate level of post-traumatic stress. Taken together, our research indicates that BMT affects the life of the child at home and at school and that post-traumatic stress symptomatology is a component of the psychological reaction in siblings. The psychosocial adjustment of siblings is a critical area of investigation in BMT populations. Parents need to know that the BMT process affects every member of the family system, and both parents and professionals need to direct more emotional support and attention to siblings. Studies are needed that focus on interventions designed to reduce levels of sibling psychosocial maladjustment. The psychosocial developmental model of post- traumatic stress disorder is a viable theoretical model that may be used to guide future research.

“Throwing Baby out with the Bath water#x201D;: Some Reflections on the Evolution of Reproductive Technology}

This article discusses section 156 of the Criminal Justice and Public Order Act 1994 which prohibits the use of eggs from aborted female foetuses for the purposes of reproduction. I argue that the pre-legislative debates focus only on the biological relationship between the aborted foetus and any ensuing child and foreclose the possibility of useful discussion about the potential merits of such technology. Kristeva's theory of abjection has been used in order to elucidate the strength of feeling about the use of eggs from the expelled foetus. I suggest that the ‘yuk’ factor stems from the potential for the blurring of the boundaries between life and death. In addition, I suggest that the stress placed on the biological link means that the foetus is ascribed special properties not given to live donors. Woman's very crucial role in reproductive technologies is therefore erased. The article argues that there are very good reasons why the debate on the subject should remain open. At present women donors have to undergo highly intrusive procedures in order to give eggs and the process is not without its health risks. The use of eggs from aborted foetuses certainly raises important consent issues but these could be addressed by placing women at the centre of the decision making process, starting with the recognition that it is women and not foetuses who have the remit and responsibility for giving consent for the use of their genetic material. Moreover, there should be an acknowledgement that women are perfectly capable of making informed decisions about donation and of considering the potential implications of participating in egg donation.

Ericksonian Hypnosis and Approaches with Pediatric Hematology Oncology Patients

This paper describes the applicability of Ericksonian hypnosis and hypnotherapy approaches with Pediatric Hematology/Oncology patients. Ericksonian hypnotherapy enable the clinician to intervene creatively and informally with the utilization approach. Interspersed suggestions in daily conversations weave in hypnotherapeutic strategies of pacing, leading, reframing, relaxation, imagery, storytelling and hypnoanalgesic techniques. These approaches are highly effective with children and easily adapted to the child's developmental needs while preserving their defenses to psychologically negotiate the various stressors of illness, including: Loss of control, fear of death, bodily changes and hair loss, intrusive and painful procedures and side effects of treatments. The child's perception of illness can be transformed into a world where they can receive comfort, gain mastery and continue to grow healthily within the medical milieu. This dynamic approach taps into the imagination of the clinician as well as the patient. Case vignettes will illustrate the benefits of these principles in easing the experience of cancer for children.

Recovery from concurrent failures in communication protocols

The reliability of communication software is desirable to meet the availability requirement of the associated communication services. Failures in the software implementing the communication protocol may result in unpredictable costs and penalties. In the past, reliability and recovery techniques for communication software have been proposed, but almost all of them are based on intrusive checkpointing procedures, which are invoked periodically. We present an efficient recovery algorithm, which, when incorporated in the protocol design, yields a protocol that can tolerate multiple concurrent failures. The fault tolerance of the recovery algorithm is achieved in two ways: the recovery algorithm can recover from multiple concurrent failures with minimum penalty, and it can recover from failures occurring during the recovery process itself. The recovery algorithm described is based on the concept of event indices and maximally reachable event tuples. During normal operation of the protocol, the state information required for a recovery is piggy-backed with the normal protocol messages. As a result, no overhead in checkpointing is introduced while executing the protocol. Our algorithm requires minimal rollback in case of failure and can handle multiple concurrent failures. A detailed discussion and an example are presented.

Hypnosis in the Treatment of Patients with Severe Burns

Burn injuries are a frequent form of trauma, the care for which typically involves repeated, intrusive procedures and acute, excruciating levels of pain. Although research in the use of hypnosis with burn patients is largely anecdotal there is emerging evidence that the burn unit may be one of the most useful arenas for the clinical application of this technique. The acute, identifiable nature of burn care procedures and the emotional state of patients in trauma care both provide an often receptive setting for the use of this intervention.

A unified approach to fault-tolerance in communication protocols based on recovery procedures

Discusses fault tolerance in computer communication protocols, modeled by communicating finite state machines, by providing an efficient algorithmic procedure for recovery in such systems. Even when the communication network is reliable and maintains the order of messages, any kind of transient error that may not be detected immediately could contaminate the system, resulting in protocol failure. To achieve fault-tolerance, the protocol must be able to detect the error, and then it must recover from that error and eventually reach a legal (or consistent) state, and resume its normal execution. A protocol that possesses the latter feature of recovering and continuing its execution starting from a legal state is also called a self-stabilizing protocol. Our recovery procedure does not require the application of an intrusive checkpointing procedure. The stable storage requirement for each process is less than that required for other proposed recovery procedures. The recovery procedure provides us with a legal protocol state, which is the global state before reaching any illegal state and before the effects of the error make other states illegal. Only a minimal number of processes affected by error propagation are required to rollback. Our recovery procedure can be used to recover from any number of transient errors in the system. Our recovery procedure has also been modeled in PROMELA, a language to describe validation models, which shows the syntactic correctness of our recovery protocol design. Finally, our procedure is compared with the existing approaches of handing the errors, and an illustrative example is provided.

An intrusive and restrictive alternative to contingent shock

AbstractA 31‐year‐old man, a New Zealander with severe developmental disability, engaged in life‐threatening operant vomiting. His therapists and two consultant behavior analysts recommended applying for a Court order to evaluate treatment that included the short‐term use of contingent shock. In Court, others gave expert testimony that positive procedures alone would be sufficient and effective. Following the Court's decision against contingent shock, professionals who were responsible for ensuring compliance with the decision did not identify a nonaversive intervention. Consequently, the client was subjected to an intrusive medical procedure (chronic nasogastric intubation) and a severely restricted environment. This intervention was continued for 1 year. Problems that resulted from conflicting expert testimony on treatment alternatives are discussed.

Post‐traumatic stress after childhood cancer I: The role of appraisal

AbstractLife threat or physical injury have been shown to produce post‐traumatic stress symptoms in children. Recent studies have demonstrated that a subset of survivors of pediatric cancer report post‐traumatic stress symptoms years after completing successful treatment. However, it is not clear whether these symptoms represent a response to the perception of life‐threat or to the repeated intrusive procedures that accompany cancer treatment. In this exploratory study, 30 childhood cancer survivors 8 to 19 years old, who were at least 22 months off treatment without recurrence of disease, were evaluated using self‐report questionnaires. The survivor's appraisal of treatment intensity signficantly correlated with the severity of post‐traumatic stress symptoms. When age at the time of diagnosis was evaluated, appraisal of treatment intensity was significantly correlated with symptoms only in those six years old and younger. For children aged seven years or older at the time of diagnosis, duration of treatment was a significant contributor to symptoms. Diagnostic category (leukemia or solid tumor), length of time since completion of treatment and the child's appraisal of life‐threat were not significantly correlated with severity of post‐traumatic stress symptoms. Further study of the impact of intensive pediatric treatment on children and the importance of developmental factors in traumatic response to illness appears to be indicated.

An efficient recovery procedure for fault tolerance in distributed systems

In this article, the problem of fault tolerance in real-time distributed systems is addressed by providing an efficient algorithmic procedure for recovery in such systems. Our recovery procedure does not require the application of an intrusive checkpointing procedure, but uses contextual information exchanged between the distributed system components during normal system progress. On detection of a failure, each process, through an efficient propagation mechanism, will have locally computed a recovery point that is mutually consistent with the recovery points computed by other processes. During recovery, each process considers the contextual information recorded after its established recovery point; a minimal amount of computations are redone. Also, a minimal number of processes are required to roll back, and the time needed to revert to normal operation is found to be minimal, thus contributing to the real-time requirements for such systems. Furthermore, the stable storage requirement needed to implement our recovery procedure is bounded and minimal. Proofs of correctness of our procedure are provided, in particular, the absence of orphan messages, message losses, and duplications is shown. An example illustrating our recovery procedure is also provided.

The relationship between functional assessment and treatment selection for aggressive behaviors

Functional assessment seeks to elucidate the variables controlling a maladaptive behavior. Based on such an assessment, effective treatments can be designed that focus on replacing that maladaptive behavior with a functionally equivalent adaptive prosocial behavior. This technique has been promoted as an effective means of improving treatments by increasing the focus on skill development and reducing the use of aversive and restrictive procedures. The literature for the behavioral treatment of aggression for persons with mental retardation or developmental delays was examined from 1979 through 1990. During that period the use of functional assessment and skill training increased; however, the increased use of functional assessment did not result in the reduced use of intrusive procedures. Potential reasons for these results are discussed, and a call for an increased emphasis on functional assessment methodology is made.

A case of phenobarbital exacerbation of a preexisting maladaptive behavior partially suppressed by chlorpromazine and misinterpreted as chlorpromazine efficacy

An adult female with developmental disability was prescribed chlorpromazine for the target behaviors of aggression and self-injurious behavior (SIB), and she was prescribed phenobarbital for seizures. Upon a chlorpromazine minimal effective dose reduction, target behaviors increased and dosage was returned to prior levels with the conclusion that chlorpromazine was controlling the target behaviors. Upon subsequent reduction and discontinuation of phenobarbital, however, chlorpromazine was able to be reduced with no increase in target behaviors. Ten years of behavioral data are presented to support the hypothesis that phenobarbital was exacerbating maladaptive behaviors. Given tardive dyskinesia (TD), clinicians and interdisciplinary teams should remain alert to the following client profile: (1) prescribed phenobarbital (or primidote), (2) prescribed neuroleptics, especially at high dosages, to control maladaptive behaviors, (3) failure of neuroleptic gradual minimal effective dose attempts, and (4) possible presence of behavioral procedures, especially intrusive procedures, to control maladaptive behaviors. This profile should trigger a “red flag” as to the possibility of phenobarbital behavioral side effects or exacerbation of preexisting maladaptive behaviors.

The nursing care of children during intrusive procedures

The nursing care of children during intrusive procedures

Personal control and the birth environment: comparisons between home and hospital settings

The purpose of this study was to investigate the factors which influenced experienced control during childbirth in low-risk women choosing two different birth environments. Eighty women choosing hospital birth and 80 choosing home birth were interviewed prenatally and again at two weeks postpartum. Those who chose home birth had a greater degree of affiliation with caregivers and more freedom of exploration and self-expression, while those who gave birth in hospital experienced more aversive stimuli (intrusive procedures and unfamiliar people). The home birth group had significantly higher levels of perceived control during childbirth. In the total sample, the combination of expectations of control and the type of childbirth setting accounted for 33·5% of the variance in perceived control scores. The findings provided partial support for a model of person-environment interaction during childbirth.