Search

BackgroundIndividuals with depression often do not respond to medication or psychotherapy. Radically open dialectical behaviour therapy (RO DBT) is a new treatment targeting overcontrolled personality, common in refractory depression.AimsTo compare RO DBT plus treatment as usual (TAU) for refractory depression with TAU alone (trial registration: ISRCTN 85784627).MethodRO DBT comprised 29 therapy sessions and 27 skills classes over 6 months. Our completed randomised trial evaluated RO DBT for refractory depression over 18 months in three British secondary care centres. Of 250 adult participants, we randomised 162 (65%) to RO DBT. The primary outcome was the Hamilton Rating Scale for Depression (HRSD), assessed masked and analysed by treatment allocated.ResultsAfter 7 months, immediately following therapy, RO DBT had significantly reduced depressive symptoms by 5.40 points on the HRSD relative to TAU (95% CI 0.94–9.85). After 12 months (primary end-point), the difference of 2.15 points on the HRSD in favour of RO DBT was not significant (95% CI –2.28 to 6.59); nor was that of 1.69 points on the HRSD at 18 months (95% CI –2.84 to 6.22). Throughout RO DBT participants reported significantly better psychological flexibility and emotional coping than controls. However, they reported eight possible serious adverse reactions compared with none in the control group.ConclusionsThe RO DBT group reported significantly lower HRSD scores than the control group after 7 months, but not thereafter. The imbalance in serious adverse reactions was probably because of the controls' limited opportunities to report these.

BackgroundRefractory depression is a major contributor to the economic burden of depression. Radically open dialectical behaviour therapy (RO DBT) is an unevaluated new treatment targeting overcontrolled personality, common in refractory depression, but it is not yet known whether the additional expense of RO DBT is good value for money.AimsTo estimate the cost-effectiveness of RO DBT plus treatment as usual (TAU) compared with TAU alone in people with refractory depression (trial registration: ISRCTN85784627).MethodWe undertook a cost-effectiveness analysis alongside a randomised trial evaluating RO DBT plus TAU versus TAU alone for refractory depression in three UK secondary care centres. Our economic evaluation, 12 months after randomisation, adopted the perspective of the UK National Health Service (NHS) and personal social services. It evaluated cost-effectiveness by comparing the net cost of RO DBT with the net gain in quality-adjusted life-years (QALYs), estimated using the EQ-5D-3L measure of health-related quality of life.ResultsThe additional cost of RO DBT plus TAU compared with TAU alone was £7048 and was associated with a difference of 0.032 QALYs, yielding an incremental cost-effectiveness ratio (ICER) of £220 250 per QALY. This ICER was well above the National Institute for Health and Care Excellence (NICE) upper threshold of £30 000 per QALY. A cost-effectiveness acceptability curve indicated that RO DBT had a zero probability of being cost-effective compared with TAU at the NICE £30 000 threshold.ConclusionsIn its current resource-intensive form, RO DBT is not a cost-effective use of resources in the UK NHS.Declaration of interestR.H. is co-owner and director of Radically Open Ltd, the RO DBT training and dissemination company. D.K. reports grants outside the submitted work from the National Institute for Health Research (NIHR). T.L. receives royalties from New Harbinger Publishing for sales of RO DBT treatment manuals, speaking fees from Radically Open Ltd, and a grant outside the submitted work from the Medical Research Council. He was co-director of Radically Open Ltd between November 2014 and May 2015 and is married to Erica Smith-Lynch, the principal shareholder and one of two directors of Radically Open Ltd. H.O'M. reports personal fees outside the submitted work from the Charlie Waller Institute and Improving Access to Psychological Therapy. S.R. provides RO DBT supervision through her company S C Rushbrook Ltd. I.R. reports grants outside the submitted work from NIHR and Health & Care Research Wales. M. Stanton reports personal fees outside the submitted work from British Isles DBT Training, Stanton Psychological Services Ltd and Taylor & Francis. M. Swales reports personal fees outside the submitted work from British Isles DBT Training, Guilford Press, Oxford University Press and Taylor & Francis. B.W. was co-director of Radically Open Ltd between November 2014 and February 2015.

Background About one-third of patients who are depressed do not respond to antidepressant medication (ADM) and traditional psychotherapy shows limited benefits. However, most randomised trials have excluded the most sick patients, especially with comorbid personality disorder. Radically open dialectical behaviour therapy (RO DBT) is a new treatment targeting emotionally overcontrolled personality, which is common in refractory depression. Objective To evaluate the efficacy, cost-effectiveness and therapeutic mechanisms of RO DBT for patients with refractory depression. Design The Refractory depression: Mechanisms and Efficacy of RO DBT (RefraMED) trial was a multicentre, parallel-group, randomised trial in which participants were randomised to receive either RO DBT plus treatment as usual (TAU) or TAU alone. Participants were assessed at 7, 12 and 18 months after randomisation. Therapeutic mechanisms were explored in causal analyses. Setting Participants were recruited from three secondary care NHS organisations in the UK: Dorset, Hampshire and North Wales. Participants Patients were eligible if they were aged ≥ 18 years, had a Hamilton Rating Scale for Depression (HRSD) score of at least 15, had a current diagnosis of major depressive disorder in the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I, were suffering either refractory or chronic depression and, in their current episode, had taken an adequate dose of ADM for at least 6 weeks without relief. Patients who met criteria for dramatic-erratic personality disorder (Cluster B), bipolar disorder or psychosis or who had a primary diagnosis of substance dependence or abuse were excluded. Interventions The intervention, RO DBT, comprised 29 weekly individual sessions lasting 1 hour and 27 weekly skills classes lasting 2.5 hours. Participants allocated to TAU could access any treatment offered by the NHS or privately. Main outcome measures The reported HRSD score 12 months after randomisation and cost per quality-adjusted life-year (QALY). Results A total of 250 participants were allocated at random: 162 (65%) participants were randomised to RO DBT plus TAU and 88 (35%) were randomised to TAU. The difference between RO DBT and TAU in the primary outcome at 12 months was not statistically significant. Nevertheless, after 7 months, participants randomised to RO DBT had substantially, and significantly, reduced depressive symptoms, relative to TAU, by 5.40 HRSD points [standardised mean difference 1.03 points, 95% confidence interval (CI) 0.94 to 9.85 points; p = 0.02]. Thereafter, RO DBT remained the better treatment with net, but non-significant, reductions of 2.15 HRSD points (standardised mean difference 0.41 points, 95% CI –2.28 to 6.59 points; p = 0.29) after 12 months and 1.69 points (standardised mean difference 0.32 points, 95% CI –2.84 to 6.22 points; p = 0.42) after 18 months. Participants allocated to TAU could access any treatment offered by the NHS or privately. Participants randomised to RO DBT reported significantly better psychological flexibility and emotional coping than TAU participants; these differences increased over time. From the perspective of the NHS and personal social services, RO DBT was not cost-effective; the incremental cost-effectiveness ratio was £220,000 per QALY, which is considerably above the willingness-to-pay threshold of £30,000 set by the National Institute for Health and Care Excellence (NICE). RO DBT participants reported eight possible serious adverse reactions compared with none by TAU participants; however, we believe that this imbalance was a result of major differences in reporting opportunities. The Data Monitoring and Ethics Committee agreed that there was no reason to suspect that RO DBT was harmful. Conclusions Although RO DBT achieved the target effect size (Cohen’s d) with a d of 0.4 at the primary end point of 12 months, this was not significant. RO DBT was not cost-effective by NICE criteria. Nevertheless, RO DBT enhanced psychological flexibility and emotional coping, which are potential mechanisms of change. Limitations Analysing only 190 participants, instead of the target of 245, reduced the statistical power of the trial. Future work Future studies should aim to refine RO DBT, by maintaining clinical effectiveness while reducing costs, and to evaluate it for a wider range of overcontrolled disorders over a longer period. Trial registration Current controlled trials ISRCTN85784627. Funding This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a MRC and NIHR partnership, and will be published in full in Efficacy and Mechanism Evaluation; Vol. 5, No. 7. See the NIHR Journals Library website for further project information.

People diagnosed with a personality disorder (PD) are often a stigmatized patient group. This can affect the care they receive, their progression, and the well-being of staff caring for them. Interventions targeted at health care professionals that aim to improve attitudes toward these patients and improve staff well-being do exist; however, evidence for their effectiveness is limited. The present study compared a self-management, Acceptance and Commitment Therapy-based training intervention (ACTr) with a Psychoeducation Training (PETr) intervention in their effectiveness in improving attitudes toward PD patients, staff-patient relations, and staff well-being. Both interventions were successful at improving attitudes and measures of staff-patient relations up to 6 months after training; however, staff well-being did not change for either group. The implications for staff training and future research are discussed.

Acceptance and Commitment Therapy (ACT) is a theoretically coherent approach addressing common processes across a range of disorders. The aim of this study was to investigate the effectiveness of a group-based ACT intervention for “treatment-resistant” participants with various diagnoses, who had already completed at least one psychosocial intervention. Of 61 individuals randomized into a service-based trial comparing ACT and Treatment as Usual based on Cognitive Behavior Therapy (TAU-CBT), 45 provided data (ACT n =26; TAU-CBT n =19). Primary outcomes were measures of psychological symptoms. All participants showed reduced symptoms immediately after intervention but improvements were more completely sustained in the ACT group at 6-month follow-up. More elaborate and more fully controlled evaluations are required to confirm the findings, improve understanding of ACT processes and assess health economic benefits.

Acceptance and commitment therapy (ACT) has been shown to have broad applicability to different diagnostic groups, and there are theoretical reasons to consider its use with clients with chronic mental health problems. We report an innovative treatment development evaluation of ACT for a heterogeneous group of ”treatment-resistant clients” (N = 10) who had attended a mean of 3.5 previous psychological interventions. All clients had Axis I presentations and half met diagnostic criteria for Axis II disorders. Functioning, assessed at pre- and postintervention, and at 6- and 12-month follow-up, showed improvements over time on all primary outcome measures, driven largely by significant changes occurring between baseline and 6-month follow-up. Improvements were associated with ACT processes of change. The data thus suggest that a broad range of clients who had not benefited from standard care may benefit from ACT.

Although Discrete-trial Teaching (DTT) is effective in teaching a many skills to children with autism, its proper implementation requires rigorous staff training. This study used an interactive computer simulation program ("DTkid") to teach staff relevant DTT skills. Participants (N = 12) completed two sets of pre-tests either once (n = 7) or twice (n = 5) before brief DTkid training. These evaluated (a) simulated interactive teaching using DTkid and (b) in vivo teaching of three basic skills (receptive and expressive labeling; verbal imitation) to children with autism. Post-tests showed that DTkid training, rather than repeated testing, was significantly associated with improvements in staff's ability to implement DTT both within the simulation and in vivo, and that the skills acquired showed both stimulus and response generalization.

The authors report 1-year outcomes for 11 children (3-7 years) with autism who attended an “Applied Behavior Analysis (ABA) classroom” educational intervention in a mainstream school setting. The children learned new skills by the end of 1 year and learned additional skills during a 2nd year. Group analysis of standardized test outcomes (IQ and adaptive behavior) showed moderate to large effect size changes over 1 year, with further changes during a 2nd year. Standardized test outcomes for nine children after 2 years were also analyzed against a comparison group ( n = 18) of children with autism receiving “education as usual.” These controlled comparisons were associated with statistically significant large effects in favor of the ABA group for adaptive skills. Exploratory analysis also showed that increases in language and learning skills in the ABA class group were generally associated with positive changes in standardized test scores. A comprehensive behavioral intervention model can be successfully implemented in a mainstream school setting.

Evidence from recent meta-analytic and narrative review suggests that early intensive behavioral intervention (EIBI) may improve life chances of preschool children with autism. Unfortunately, there are few data indicating whether early gains are maintained after intervention ceases. The purpose of the present study was to establish the 2-year follow-up outcome for children with autism ( N = 41) who had participated in an earlier 2-year controlled comparison of EIBI. Twenty-three children in the intervention group (100% of original sample) and 18 in the treatment-as-usual comparison group (86% of original sample) were located and retested. Group differences favoring intervention substantially diluted in this period but varied significantly between subgroups who had received university-supervised and parent-commissioned interventions, favoring the latter. These groups differed in terms of their baseline characteristics and intensity of intervention. Results strongly suggest a need for better characterization of those children who would benefit from more active maintenance programs.

Although theoretical and clinical literature emphasize the role of both an unwillingness to experience emotional distress and physical pain tolerance in deliberate self-harm (DSH), research on their associations with DSH remains limited. This study sought to examine the relationships between DSH and the willingness to experience emotional distress and tolerate physical pain, including the moderating role of interpersonal distress in these relationships. To this end, young adults with recent DSH (n = 43) and controls without any DSH (n = 52) were randomly assigned to 1 of 2 emotion-induction conditions (distressing or neutral), after which behavioral measures of both the willingness to experience distress and physical pain tolerance were obtained. Consistent with hypotheses, findings indicated heightened physical pain tolerance among self-harming individuals only under conditions of interpersonal distress. Furthermore, findings provided some support for the hypothesized association between DSH and the unwillingness to experience emotional distress, suggesting that self-harming women evidence less willingness to experience emotional distress only under conditions of depleted regulatory capacity (eg, following an interpersonal stressor).

The purpose of this study was to investigate novices learning to use a mission planning system. Novice participants received one training session, followed by three test sessions. This was compared to expert performance. During the test sessions, all participants were required to ‘think aloud’, based on Ericsson and Simon's Ericsson, K.A. and Simon, H.A., 1993. Protocol analysis: verbal reports as data . Revised ed. Cambridge, MA: The MIT Press description of the technique. Objective measures of time to complete the task, number of errors made, mouse travel and number of mouse clicks were also recorded. It was hypothesised that error, time and mouse data would reflect the acquisition of skill and improved problem-solving abilities. The verbal data were analysed in an exploratory fashion to see what changes individuals experienced. The results of the study showed that participants acquired a level of skill across sessions, and that the cognitive processes reflected in the verbal protocols changed as a function of this skill acquisition. These changes in cognitive processing mirrored a number of the differences between novices and experts.

The terms used to denote the concepts of mental handicap and challenging behaviour are a matter of continuing controversy. In the first part of this paper, research concerned with evaluating the impact of such labels is reviewed, and the value of a semantic technique for assessing the connotative effect of labels is proposed. In the second part, this approach was evaluated in a study in which undergraduate social science and science students completed rating scales for terms currently in use to describe mental handicap and challenging behaviour. There were marked differences in the connotations of terms with very similar denotations. Specifically, recently coined terms (e.g. ‘learning difficulty’, ‘challenging behaviour’) were rated more favourably than more familiar descriptions (e.g. ‘mental retardation’, ‘problem behaviour’). Nevertheless, virtually all the terms assessed carried negative, rather than neutral or positive, connotations. These results are discussed in terms of the need to devise descriptions that will promote more positive social representations of mental handicap.

The authors report two experimental studies which addressed the question of how children with mental handicaps can be taught to generate productive, two-sign combinations; that is, correctly to recombine signs in a way not previously taught. The basic approach, matrix training, involved teaching a specific subset of sign combinations corresponding to the overlapping diagonal items in a matrix of all possible combinations. In Experiment 1, the matrix items consisted of stimuli produced by combining character and facial expression elements. In Experiment 2, the matrix was formed from colour and object elements. In both studies, matrix training was successful in teaching children to use multiple signs to label the multiple attributes of training items. However, the productive recombination of signs only occurred in Experiment 2, with children who, prior to matrix training itself, had acquired sign labels for the elements which made up the matrix.

The authors report two experimental studies which looked at the effects of a matrix training procedure designed to teach children with mental handicaps to use two-sign combinations. Matrix training involves teaching a specific subset of sign combinations which correspond to the overlapping diagonal cells in a matrix of possible sign combinations. Each study used a matrix of object and location combinations. In the first study, two children were successfully taught to make correct two-sign combinations, following the teacher's placement of an object in a location. The skill was acquired as a generalised response class, but neither child fully acquired the ability to use sign order to convey meaning. The second experiment showed that only two of four children, who used signs in combination in the natural environment, were sensitive to the linguistic information carried by sign order. An attempt was made to teach the meaning of sign order to the children who were not sensitive to it. A matrix of sign combinations was used, in which the signs functioning as objects could be transposed with those which functioned as locations. These procedures were not successful. The results are discussed with respect to the complex relationships between sign learning and natural language.

This paper reports two experiments that investigated the role of verbal behavior in the emergence and generalization of contextually controlled equivalence classes. During both experiments, participants were trained with two different combinations of the same easily nameable, yet formally unrelated, pictorial stimuli. Match-to-sample baselines for eight four-member classes were established under the contextual control of two colors. In the presence of one color, conditional relations were established between stimuli whose normative names rhymed. In the presence of the other color, conditional relations were established between stimuli whose normative names did not rhyme. Although, during Experiment 1, all participants demonstrated equivalence classes involving rhyming stimuli, none demonstrated the formation of nonrhyme equivalence classes. To investigate this finding, Experiment 2 evaluated whether participants would demonstrate both rhyme and nonrhyme equivalence classes given more extensive exposure to the experimental contingencies. All participants demonstrated contextually controlled rhyme and nonrhyme equivalence classes, although rhyme classes were demonstrated with greater facility than nonrhyme classes. Results indicate that visual stimuli are named, that verbal bases for stimulus classification can affect the emergence of contextually controlled equivalence classes, and that untrained contextually controlled conditional discriminations involving novel stimuli can emerge on the basis of participants' verbal behavior.

Past research has demonstrated that older adults are more likely than younger adults to exhibit information selectivity in decision making. Two alternative explanations have been proposed to account for this age difference. One explanation attributes the increase in information selectivity to older adults' reliance on prior knowledge, whereas the other explanation suggests that it reflects reduced information processing capacity. The aim of this research was to explore the latter explanation by controlling for experiential factors and varying the cognitive demands involved in decision making. Specifically, participants were faced with unfamiliar decision problems, and had to base their decisions on the available information in order to reach a desired goal. In Experiment 1 younger and older participants were required to play a game involving chance. The outcome payoff was varied between three conditions (approach, avoidance, and control). The results indicated that both the younger and the older participa...

Background: Patients diagnosed with a personality disorder (PD) are often stigmatized by the healthcare staff who treat them. Aims: This study aimed to compare the impact on front-line staff of a self-management Acceptance and Commitment Therapy-based training intervention (ACTr) with a knowledge- and skills-based Dialectical Behaviour Training intervention (DBTr). Method: A service-based randomized controlled trial was conducted comparing the effects of 2-day ACTr (N = 53) and DBTr (N = 47) staff workshops over 6 months. Primary outcome measures were staff attitudes towards patients and staff-patient relationships. Results: For both interventions, staff attitudes, therapeutic relationship, and social distancing all improved pre- to postintervention, and these changes were maintained at 6-month follow-up. Conclusions: Although offering different resources to staff, both ACTr and DBTr were associated with an improved disposition towards PD patients. Future research could evaluate a combined approach, both for staff working with PD patients and those working with other stigmatized groups.

Systemic analyses of psychological functioning in families of children with autism have typically shown that parents report different experiences (e.g., stress) and that siblings may also be affected. The purpose of the present research was more explicitly to address relationships between child, partner, and parent variables. Parents of 48 children with autism (41 mother-father pairs) reported on child characteristics, and their own stress and mental health. Mothers were found to report both more depression and more positive perceptions than fathers. Regression analyses revealed that paternal stress and positive perceptions were predicted by maternal depression; maternal stress was predicted by their children's behavior problems (not adaptive behavior or autism symptoms) and by their partner's depression. The future testing of the mechanisms underlying these results is discussed. In addition, the need is emphasized for more systemic analyses to understand the psychological functioning of children with autism and their siblings and parents.

Incentive sensitisation theory (IST) claims that the mechanism of reward is comprised of separate neurobiological systems of wanting and liking, that dependent drug use occurs as a result of sensitisation of the system controlling wanting, and that the two systems can be dissociated. To test the IST prediction that wanting and liking for alcohol can be dissociated in humans. Measures of wanting and liking for alcohol were obtained in three experiments. Experiment 1 examined whether liking for alcohol was associated with levels of wanting, as indexed by self-reported weekly alcohol intake. Experiments 2 and 3 also assessed the association between liking and wanting but in these experiments wanting was also indexed by alcohol consumption in the laboratory. Experiment 2 increased wanting for alcohol using an alcohol priming dose to determine whether liking would be similarly affected. Experiment 3 reduced liking for alcohol by adulterating drinks with Tween to see whether wanting would also be reduced. Little evidence for an association between liking and wanting for alcohol was found in Experiments 1–3 but, collapsing across all experiments, a weak positive correlation between liking and wanting was found. However, in Experiment 2, wanting was increased by the alcohol priming dose whereas liking was not and in Experiment 3 liking was reduced without a concurrent reduction in wanting. Although correlations between wanting and liking can be observed these results support the contention of the IST that wanting and liking for alcohol can be dissociated in human participants.

The dual pathway model proposes the existence of separate and neurobiologically distinct cognitive (inhibitory and more general executive dysfunction) and motivational (delay aversion) developmental routes to AD/HD. The study reported in this paper explores the relation between inhibitory deficits and delay aversion and their association with AD/HD in a group of three-year-old children. Children identified as having a pre-school equivalent of AD/HD (N=19) and controls (N=19), matched for gender and IQ, completed a battery of inhibition and delay tasks. Correlational and factor analysis supported a dissociation between inhibitory deficits (go-no-go, set shifting) and delay aversion (choice delay) with delay of gratification cross-loading. Children with AD/HD displayed more inhibitory deficits and were more delay averse than controls. The data support the value of the distinction between motivational and cognitive pathways to AD/HD. Furthermore, the data suggest that such a distinction is apparent relatively early on during development.

The functionality of verbal behavior in equivalence class formation was demonstrated by training 30 verbally able adults using different combinations of the same easily nameable, yet formally unrelated, pictorial stimuli. Match-to-sample baselines for four four-member classes were established sequentially (i.e., AB-BC-CD), with participants in the rhyme condition trained to select comparisons whose normative names rhymed with those of the samples. For the orthogonal condition, class rearrangement was such that on every trial all available comparisons' names rhymed with each other, but not with the name of the sample. In the diagonal condition, stimuli were allocated pseudorandomly as samples and comparisons. Although all participants maintained baseline discriminations prior to emergent testing, equivalence was confined almost exclusively to the rhyme condition, in which it was ubiquitous. These participants also required less training than those in the control conditions, among whom effects of nodal distance were observed most strongly. Subsequent testing presented participants with no-reinforcement trials involving novel pictorial stimuli, in which one of the available comparisons' names always rhymed with that of the sample. All rhyme participants consistently selected these comparisons. Results indicate that visual stimuli are named, that the phonological properties of those names can influence equivalence class formation, and that the emergence of untrained discriminations may, under certain circumstances, be rule governed.

Adult human participants experienced 200 trials in which they repeatedly chose between two immediately available rewards of different magnitudes (points exchangeable for money). Although choosing the larger reward always resulted in more points per trial, choosing the smaller reward increased the magnitude of both rewards on the next trial. Thus consistent choice of the smaller reward resulted in a greater average number of points overall. This effect on global (overall) reinforcement rate was gradual and difficult to perceive by comparison with the (opposed) difference in points between the two alternatives on a given trial (local rate). Participants generally preferred the larger reward and thus failed to maximize the global reinforcement rate. Preference for this higher local rate of reinforcement increased when the difference in local rates was larger. However, when the salience of the global contingency was enhanced by providing cognitive or social comparative information, participants chose the larger reward less often and thus increased global reinforcement rate.

Although theoretically-oriented behaviour analysts have always claimed that operant psychology offers a framework for understanding all aspects of human behaviour, their practically-minded colleagues have tended to focus their efforts on helping people with long-term and often intransigent difficulties. Thus behaviour analysis and the remediation of people with intellectual disability go back a long way together. As with any long-term relationship, there have been both peaks and troughs, times of great harmony and periods of misunderstanding and conflict. The aim of this evaluative review is to describe the history of the alliance between caregivers and educators of people with intellectual disability on the one hand, and researchers and interventionists with a behaviour analytic orientation on the other. The review considers both the strengths and weaknesses of applied behaviour analysis in this context, highlighting areas where further growth and development can still be expected. Particular emphasis is...

If people with learning disabilities are to be effective social agents, the capacity to communicate with others through speech, sign or symbol manipulation is of central importance. Unfortunately, severe and profound learning disabilities are frequently associated with very poor communicative skills and remediation is therefore essential. Theories of normal language development may be of value in suggesting remedial strategies but, of these, structural approaches that emphasise language organisation are less helpful than functional accounts of language use. The latter have led to many successful intervention programmes based in the domestic and social environments of learners. Research is continuing to produce rapid progress in communication intervention but the application of scientific findings is critically dependent on high levels of understanding by, and co‐operation between, professionals in such disciplines as nursing, clinical psychology, speech therapy, teaching and management.

Cues associated with familiar alcoholic drinks such as beer may, through repeated association with the unconditioned stimulus properties of alcohol, acquire the status of classically conditioned stimuli. It has been proposed that such drug-related conditioned stimuli mediate drug tolerance. Thus, the aim of the present experiment was to test this proposition on cognitive, subjective, and psychophysiological indicators of alcohol tolerance using human subjects. Two groups of subjects received alcohol in the form of a familiar drink (beer) or an unfamiliar drink (blue peppermint mixture). Both drinks contained the same dose of alcohol and were consumed at the same rate. Although conditioned heart rate and skin conductance responses occurring while subjects looked at and tasted the test drinks were weak, there were strong indicators of conditioned tolerance on the performance measures following consumption. Subjects who consumed the unfamiliar drink were significantly poorer on cognitive and motor tasks, and they rated themselves more intoxicated than did those who consumed the familiar drink.

The methods used in Sidman's original studies on equivalence classes provide a framework for analyzing functional verbal behavior. Sidman and others have shown how teaching receptive, name-referent matching may produce rudimentary oral reading and word comprehension skills. Eikeseth and Smith (1992) have extended these findings by showing that children with autism may acquire equivalence classes after learning to supply a common oral name to each stimulus in a potential class. A stimulus class analysis suggests ways to examine (a) the problem of programming generalization from teaching situations to other environments, (b) the expansion of the repertoires that occur in those settings, and (c) the use of naming to facilitate these forms of generalization. Such research will help to clarify and extend Horne and Lowe's recent (1996) account of the role of verbal behavior in the formation of stimulus classes.

The behavior of staff who care for people with mental retardation has been identified as a significant factor in the development and maintenance of challenging behaviors. In a recent analysis, Hastings and Remington (1994a) suggested that both environmental contingencies and rules from other people may affect staff actions. The present study tested this analysis by asking participants to respond to a computer simulation of a work situation involving the care of two individuals who engaged in self-injurious behavior. Fifty participants "interacted" with an attention-seeker and a social-avoider on a simulated teaching task. Results showed that rules were the main factor governing performance. The aversive nature of the contingencies between the self-injury and participants' "attending" behavior also appeared to be influential. The implications of these results for work with care staff, the analysis of challenging behaviors, and experimental research on rule-govemed behavior are discussed.

Acceptance and Commitment Therapy (ACT) emphasizes the relationship a person has with their thoughts and beliefs as potentially more relevant than belief content in predicting the emotional and behavioral consequences of cognition. In ACT, "defusion" interventions aim to "unhook" thoughts from actions and to create psychological distance between a person and their thoughts, beliefs, memories, and self-stories. A number of similar concepts have been described in the psychology literature (e.g., decentering, metacognition, mentalization, and mindfulness) suggesting converging evidence that how we relate to mental events may be of critical importance. While there are some good measures of these related processes, none of them provides an adequate operationalization of cognitive fusion. Despite the centrality of cognitive fusion in the ACT model, there is as yet no agreed-upon measure of cognitive fusion. This paper presents the construction and development of a brief, self-report measure of cognitive fusion: The Cognitive Fusion Questionnaire (CFQ). The results of a series of studies involving over 1,800 people across diverse samples show good preliminary evidence of the CFQ's factor structure, reliability, temporal stability, validity, discriminant validity, and sensitivity to treatment effects. The potential uses of the CFQ in research and clinical practice are outlined. © 2013.

In her commentary on our integration of the literature on challenging behaviours and care staff behaviour (Hastings & Remington, 1994b), Clegg (1994) discussed three main issues. Firstly, she argued that a behaviour analytic approach to challenging behaviours is «deeply impoverished». Secondly, she claimed that our analysis laid the blame for challenging behaviours on the shoulders of care staff, Finally, she presented our philosophical position as objectivist. In this paper, we reply to these comments by summarizing the richness and considerable potential of an approach to challenging behaviours based on behaviour analytic theory. This summary serves to clarify the fact that we consider care staff behaviour, including actions that may contribute to the development and maintenance of challenging behaviours, to be under the control of environmental contingencies and verbal rules that are part of the service environment

Recent experiments with human subjects have shown that drug cues (e.g. sight of beer or needle and syringe) elicit different responses than do neutral stimuli. However, because conditioning has not been carried out in the majority of cases, it is not clear why drug cues have different response eliciting capacities; associative and non-associative mechanisms may both play a part. In this experiment a counterbalanced differential conditioning procedure was used to isolate the role of associative processes in the development of physiological, behavioural, and subjective conditioned responses to cues for alcohol over the course of repeated conditioning sessions. Twelve healthy volunteers took part in the experiment which involved each subject attending for ten sessions. On physiological measures evidence was found for conditioning of skin conductance and cardiac inter-beat interval responses to cues for alcohol delivery. Over the course of conditioning on behavioural measures of drink consumption there were changes in the rate of consumption and number of sips taken as a function of whether or not the drinks contained alcohol. Finally, on subjective measures, there was a differential change in subjective state in response to alcohol and soft drink expectancy as conditioning progressed.

Many people with learning disabilities engage in challenging behaviours which, behaviour analytic models suggest, are social behaviours sensitive to the actions of others in the environment. In this paper, the research literature on the behaviour of staff, especially that pertaining to interactions with people with challenging behaviours, is reviewed. Empirical evidence is found to support the hypothesis that staff actions affect clients' challenging behaviours. In addition, studies of staff behaviour show that their behaviour is often counter-habilitative. Firstly, staff spend little time interacting with clients and the quality of these interactions is often poor. Secondly, observational studies have shown that staff respond intermittently to challenging behaviours, and self-report studies indicate that many of these responses are of a nature that may reinforce such behaviours. Finally, although limited, evidence suggests that behavioural programmes for clients with challenging behaviours are rare and where they do exist they are often not carried out by staff. To date, interventions for staff behaviour (training and management approaches) have acted to change these ways of behaving but have not been founded on adequate analyses of staff action. A call is made for analyses of staff behaviour, and other implications for research and practical work with staff are discussed.

May I begin by expressing my sincere thanks to Phonic Ear for their very generous support and to Lyle Lloyd and the other members of the AAC Editorial Board who selected me for this award. I am truly grateful to all concerned. Phone calls late at night have always bothered me. If it can’t wait until morning, it’s probably bad news. I have Lyle Lloyd to thank for helping me to re-evaluate a lifelong anxiety. His call to tell me that I had been honored with the opportunity to present this lecture certainly arrived late at night; but he was making it in the Indiana afternoon, several time zones back across the Atlantic, and it was very good news indeed. I basked in the glow of it: a prestigious award, presented by a distinguished group of people for whom I have the greatest respect, and in such a wonderful place. I thought about leaving England in November — doing rather more than just “California dreaming on such a winter’s day.” Lyle didn’t need to do any persuading. I don’t know what previous Distinguished Lecturers have done after they’ve put the phone down, but I started to worry. With scarcely a thought, I had committed myself to a title: Augmentative and Alternative Communication and Behavior Analysis: A Productive Partnership? Now I had to figure out what precisely I meant by it, and suddenly November started to seem very close. This was in May, and I’ve been thinking about it ever since. Come to think of it, perhaps late night calls still do bother me.

Clinicians frequently encounter problem behaviors such as self-harm, restrictive eating, binge eating, alcohol misuse, drug misuse, smoking, sexual promiscuity, internet addiction, excessive exercise, and aggression. Although these behaviors commonly co-occur, no scale exists to measure them concurrently. Based on data from two opportunity samples (N = 691 and N = 53), this study designed and validated a composite measure of the problem behaviors noted above. The Composite Measure of Problem Behaviors, developed using exploratory factor analysis, demonstrated good psychometric properties. Subsequent confirmatory factor analysis, using both the first (N = 691) and a third sample (N = 740), identified a common higher order factor that accounted for covariance between behaviors. Findings thus suggest that despite the formal dissimilarity of behaviors assessed, a common function may explain their covariation.

Several previous studies have shown that when expressive signing is trained using simultaneous communication, in which both visual and spoken cues may function as discriminative stimuli for signing, children with severe mental retardation demonstrate overselectivity, usually to the visual modality. As a result, such children fail to acquire other language functions, such as speech comprehension, despite the many occasions during training that words and their referents co-occur. We report two studies, both of which used alternating treatments designs to assess the relative efficacy of two methods of overcoming overselective attention during simultaneous communication training. The first method, Extensive Sign Training, involved overtraining expressive signing in simultaneous communication, but with a reduced reinforcement schedule. The second method, Mediated Sign Training, involved training receptive speech functions prior to simultaneous communication training. In both studies, the Extensive condition pr...

One common outcome of using simultaneous communication to train the expressive use of manual signs is overselective attention to the visual component of discriminative stimuli for manual signing. Consequently, mentally retarded children may not acquire speech comprehension as a result of such training, despite the many occasions on which they experience the co-occurrence words and their referents. This study used an alternating treatment comparison to assess the relative efficacy of two methods of overcoming selective attention during simultaneous communication training. The first method, Differential Sign Training, involved mixing simultaneous communication trials with an equal number of trials in which the cue for manual signing was the referent word alone. The second method, Extensive Sign Training, involved overtraining expressive manual signing in simultaneous communication, but with a reduced reinforcement schedule. Although the Extensive condition produced the faster acquisition of expressive manua...

Previous research in expressive sign teaching has sometimes used a labeling procedure in which the reinforcers for signing are unrelated to visual referents for the signs taught. This nonspecific reinforcement strategy can be contrasted with a requesting procedure in which signing is reinforced specifically (i.e., the reinforcers for signing are the visual referents of the signs produced). This study used an alternating treatments design to make a direct comparison between the effect of the two reinforcement strategies on the acquisition of expressive signing in children with severe mental retardation. The Request treatment produced faster acquisition of expressive signing than the Label treatment for three of the subjects, but the effect was strongest in the two least able children. Although post-tests appeared to show that children could use the signs functionally regardless of the method initially used to teach them, alternative explanations of this apparent transfer of function, and their implications...

Despite their formal dissimilarity, problem behaviors (e.g., substance misuse, binge eating, self-harm) may share a common function. According to Acceptance and Commitment Therapy (ACT), this shared function is Experiential Avoidance, the process of avoiding, escaping or otherwise altering unwanted private events (e.g., thoughts, feelings, memories) and the contexts that elicit them. Structural Equation Modeling was used cross-sectionally with data from a clinical opportunity sample ( N = 290) to test (a) whether problem behavior covariance was associated with experiential avoidance, and (b) whether experiential avoidance mediated the relationships between historical and dispositional risk factors (childhood trauma and negative affect intensity, respectively) and the tendency to engage in problem behaviors. Analysis showed that experiential avoidance contributed to the covariation of problem behaviors, and that it fully mediated the relationships between both risk factors and problem behavior. Thus, experiential avoidance may be a key process to target in the management of individuals with behavior problems.

Different kinds of physiological response to stimuli which have been associated with alcohol ingestion have been observed in human subjects. A literature review shows that when subjects are exposed to alcohol associated stimuli without consuming the drinks then increases in arousal, as indexed by skin conductance and heart rate increases, tend to occur. If subjects consume drinks which have been associated with alcohol ingestion, then decreases in arousal tend to occur. Forty non-dependent drinkers were asked to either consume or hold drinks which either had a history of alcohol association or did not. Interactions were observed between the activities subjects engaged in with the drinks and the degree of alcohol association of the drinks. Presentation of alcohol associated drinks produced smaller increases in arousal than non-alcohol associated drinks if the drinks were consumed but vice versa if the drinks were just held. The results support the conclusions drawn from the literature review and have implications for current theories of conditioned responses to drug cues and the related theories of the motivational processes involved in the regulation of drug intake.

Animal studies have demonstrated decreased reward responsivity during nicotine withdrawal (e.g., Epping-Jordan et al., Nature 393:76-79, 1998) and the Card Arranging Reward Responsivity Objective Test (CARROT) has recently been used to study the effect of nicotine withdrawal on reward responsivity in humans (e.g., Al-Adawi and Powell, Addiction 92:1773-1782, 1997; Powell et al., Biol Psychiatry 51:151-163, 2002). We investigated a suggestion that nicotine withdrawal may have additional reward-related effects apart from the reward responsivity effects already observed.The objective of this study was to determine whether or not nicotine withdrawal results in slower improvements in performance on a card-sorting task over a series of trials.We carried out two experiments using a modified version of the CARROT, the mCARROT, to compare the performance of human participants in nicotine withdrawal with those who were satiated.Although withdrawal produced no direct effect on the mCARROT measure of reward responsivity, the overall sorting rate was lower, and the increase in sorting rate across successive trials was slower during nicotine withdrawal than during satiation.These data indicate that nicotine withdrawal impacted on task performance independently of the introduction of a performance contingent reward, suggesting a novel reward-related effect of nicotine withdrawal.

Introduction: Only 30–40% of depressed patients treated with medication achieve full remission. Studies that change medication or augment it by psychotherapy achieve only limited benefits, in part because current treatments are not designed for chronic and complex patients. Previous trials have excluded high-risk patients and those with comorbid personality disorder. Radically Open Dialectical Behaviour Therapy (RO-DBT) is a novel, transdiagnostic treatment for disorders of emotional over-control. The REFRAMED trial aims to evaluate the effectiveness and cost-effectiveness of RO-DBT for patients with treatment-resistant depression. Methods and analysis: REFRAMED is a multicentre randomised controlled trial, comparing 7 months of individual and group RO-DBT treatment with treatment as usual (TAU). Our primary outcome measure is depressive symptoms 12 months after randomisation. We shall estimate the cost-effectiveness of RO-DBT by cost per quality-adjusted life year. Causal analyses will explore the mechanisms by which RO-DBT is effective. Ethics and dissemination: The National Research Ethics Service (NRES) Committee South Central – Southampton A first granted ethical approval on 20 June 2011, reference number 11/SC/0146. Trial registration number: ISRCTN85784627.

Discrete-trial training (DTT) relies critically on implementation by trained tutors. We report three experiments carried out in the development of "DTkid"--interactive computer simulation software that presents "SIMon", a realistic virtual child with whom novice tutors can learn and practise DTT techniques. Experiments 1 and 2 exposed groups of participants either to DTkid training or to a control task. Participants in the former groups demonstrated significantly greater procedural and declarative knowledge of DTT. Experiment 3 confirmed this finding, further demonstrating that observation of DTkid training trials alone was sufficient to enhance participants' declarative and procedural knowledge of DTT. Results indicate that DTkid offers the potential for an effective means of teaching DTT skills to novice tutors of children with autism.

Despite the theoretical and demonstrated empirical significance of parental coping strategies for the wellbeing of families of children with disabilities, relatively little research has focused explicitly on coping in mothers and fathers of children with autism. In the present study, 89 parents of preschool children and 46 parents of school-age children completed a measure of the strategies they used to cope with the stresses of raising their child with autism. Factor analysis revealed four reliable coping dimensions: active avoidance coping, problem-focused coping, positive coping, and religious/denial coping. Further data analysis suggested gender differences on the first two of these dimensions but no reliable evidence that parental coping varied with the age of the child with autism. Associations were also found between coping strategies and parental stress and mental health. Practical implications are considered including reducing reliance on avoidance coping and increasing the use of positive coping strategies.

The variability in outcomes observed in home-based early intensive behavioral intervention for children with autism is likely in part to be the result of the quality of therapist performance. Therapist behavior in this context, however, is poorly understood. To achieve such an understanding, it will be necessary to specify how factors such as therapist, child and intervention program characteristics, as well as supervision and training provision, influence therapists’ interactions with children. This study identified facilitating factors and barriers that therapists considered to influence their capacity to deliver early intensive behavioral intervention to young children with autism. Nineteen therapists associated with various service providers in the South of England were interviewed. In general, responses represented opposite poles of the same construct. For example, child factors such as compliance and competence were considered to facilitate instruction, whereas challenging behavior and lack of progress were perceived to hinder it. These issues are considered in the light of previous research on staff behavior in related contexts. The factors identified suggest specific avenues for questionnaire and experimental research to validate these findings, have implications for routine service provision and may help improve the outcomes of children receiving early intensive behavioral intervention.