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Identifying features of ‘pathological demand avoidance’ using the Diagnostic Interview for Social and Communication Disorders (DISCO)
Get PDFThe term ‘pathological demand avoidance’ (PDA) was coined by Elizabeth Newson to describe children within the autism spectrum who exhibit obsessive resistance to everyday demands and requests (Newson et al., Arch Dis Child 88:595–600, 2003). Clinical accounts describe avoidance strategies including apparently strategic use of distraction or socially shocking behaviour, and obsessive need for control, reflected in domineering behaviour to peers and adults. Educational and management approaches effective for PDA reportedly differ from those for ‘typical’ autism spectrum disorders (ASD), and include novelty, humour and flexibility. Identification of PDA in individuals with ASD may have important implications for management (Eaton and Banting, J Learn Disabil Offending Behav 3:150–157, 2012). Despite increasing interest, no clinician-rated instrument for PDA has been developed. Here, items relevant to PDA were identified from the Diagnostic Interview for Social and Communication Disorder (DISCO) (Wing et al., J Child Psychol Psychiatry 43:307–325, 2002). The most PDA-specific subset of relevant DISCO items was selected, based on low endorsement in general across a sample of 153 individuals assessed for possible ASD using the DISCO. Having selected 11 DISCO PDA items for the measure, a subset of individuals with a high number of these features was identified (N = 27). Consistent with Newson’s descriptions, this high scoring group was characterised by lack of co-operation, use of apparently manipulative behaviour, socially shocking behaviour, difficulties with other people, anxiety and sudden behavioural changes from loving to aggression. All but one case met criteria for an ASD. This study brings the field a step closer to a clinician-rated measure of PDA features and highlights the need for further elucidation of the PDA phenotype
Doing things differently: An appreciation of Meltzer’s contribution
No full textIn this paper I wish to draw attention to aspects of Donald Meltzer’s ways of working which characterised his practice as a psychoanalyst and which I consider important in appreciating his originality. Several central themes are described and elaborated including: the central relevance of child analysis and the unity of child and adult analysis; the value of working in a clinical group with colleagues; the revision of psychoanalytic theory; joint research and writing projects; Meltzer’s recognition of the power of infant observation as a tool for learning; the commitment to a wider psychoanalytic culture; the particular contribution to the Tavistock child psychotherapy training. Examples from Meltzer’s written archive, both his books and papers, are used to demonstrate and illuminate these themes, alongside clinical material from child psychotherapy work brought to the author’s attention in supervision
A psychotherapy group for latency girls in a school
No full textThis paper describes the TOPS (Tavistock Outreach Project in primary
schools) experience of running a psychotherapy group for latency girls.
The group consisted of five girls in their final year of primary school
whose teachers felt could benefit from support in their relationship
difficulties. The group ran in the school for just under two terms of
weekly sessions and was led by a Child Psychotherapist and an Assistant
Therapist. Susan Reid's Psychodynamic group approach (1993)
underpinned the therapeutic approach used in the group.
A description of TOPS - a school based therapeutic provision, opens the
paper, followed by a brief description of the school setting, the rational
for group work and the selection criteria. The group’s development over
time and the powerful processes that took place in it are demonstrated
through the emerging themes discussed: Falling apart and coming
together, the therapy box as a trigger for chaos as linked to the
mythological story of ‘Pandora’s Box’, the group's relationship with the
group leaders, anxieties about changes and endings with the girls
imminent move to secondary School and the group’s move from a Basic
Assumption group to a Work Group (Bion, 1959). Accordingly, over
time, a slow shift in the group's’ state of mind could be observed; from
ganging against and excluding a member or the Group Leaders, to
gradually becoming more thoughtful, integrated and better accepting of
what the group and the Group Leaders had to offer – but in the context of
many returns to a gang mentality along this path.
The paper concludes with some reflection upon the outcomes of the work
and discussion of these. Despite the fairly short life of the group – 12
sessions, pleasing outcomes were reported by the teachers, parents and
the group members who saw improvement in their relationship
Women and infants in care proceedings in England: New insights from research on recurrent care proceedings
No full textPsychological aspects of child health: Workshops for paediatric trainees
No full textAims Paediatricians often see children and young people with emotional difficulties manifesting as physical illness, sometimes called medically unexplained symptoms. Mental health training for general paediatricians is often lacking which can result in over-medicalisation of the problem.
Recent political and media attention has been focused on the need to improve mental health provision for child and young people. Given the demands on Child and Adolescent Mental Health Services, attempts at improving the skills of paediatricians in assessing and treating children with medically unexplained symptoms could help ease pressure and improve care.
Methods We evaluated the impact on paediatric trainees’ confidence of a series of workshops about medically unexplained symptoms. Five workshops were facilitated by a Consultant Child and Adolescent Psychotherapist and took the form of case discussions. The primary outcome measure was trainees’ self-reported confidence in assessing and managing child and young people with medically unexplained symptoms.
Results Thirteen trainees participated in the workshops. Self-reported confidence in assessing children and young people with medically unexplained symptoms was higher after the workshops (difference in confidence +0.88, 95% CI 0.21–1.56, p = 0.023). Trainees’ confidence in formulating and discussing a management plan was also increased (difference in confidence +1.00, 95% CI 0.57–1.43, p = 0.004).
Participants identified that the workshops had increased their awareness of the psychological aspects of illness with one describing having a “better idea of the myriad of ways that psychological distress may manifest in children and young people”. Trainees also described an increasing willingness to reflect on their own response to children, young people and families with medically unexplained symptoms.
Conclusion Reflective workshops for paediatric trainees improve their confidence in assessing and managing children and young people with medically unexplained symptoms. Given that this is a common presentation to general paediatricians and that they often feel unconfident managing mental health problems, we believe such workshops could be usefully incorporated into postgraduate paediatric training. Further studies will evaluate the impact on clinical outcomes and the feasibility of multi-professional training
Multi-professional clinical leadership training in healthcare: A peer-led evaluation of the experience and benefits of the 'Darzi Fellowship'
Get PDFPurpose:
This paper examines the impact of a structured clinical leadership programme on healthcare
professionals working within the British National Health Service (NHS). Clinical leadership is
now regarded as essential in addressing the complex challenges in the NHS, yet few trainees
of any healthcare discipline receive formal training. The study describes a peer-led
evaluation of a year-long, multidisciplinary, experiential programme, the ‘Darzi Fellowship’,
based in London.
Design:
An anonymous survey was analysed using a mixed-methods approach. Individual and
collective experiences of fellows were evaluated, in particular the perceived impact the
fellowship had on:
1) the fellows themselves,
2) their ‘host’ organisation, and
3) the NHS as a whole
Findings
A 90% return rate was achieved. 94% reported that the experience had been valuable to
them, 85% feeling more empowered to effect change in healthcare systems. Crucial
mechanisms to achieve this included increased self-awareness, personal reflection and the
freedom to gain a greater understanding of organisations. Particular emphasis was placed
on the value of developing clinical networks which promote collaboration across
boundaries. Fellows emerged as more reflexive, critical and strategic thinkers.
Practical implications:
This paper demonstrates the positive impact that clinical leadership training can have on
participants, and the mechanisms by which future leaders can be created.
Value:
Our novel, non-commissioned, peer-initiated and peer-led evaluation describes the personal
experiences of Fellows in a unique, multidisciplinary clinical leadership programme. We
hope this will inform the development of future schemes in the NHS and provide learning
for an international healthcare audience
'Another door into a new world waiting to be explored’: A psycho-social investigation into the transition experiences of young adults with autism using the Grid Elaboration Method
No full textTransition research tends to consider the experiences of ‘typically developing’ pupils and focusses on the primary to secondary school transition. Accounts that specifically focus on the views of pupils with autism also tend to rely heavily on the accounts of parents and staff. This study aimed to explore the transition experiences of young adults on the autism spectrum from the perspective of the young people themselves, having an exploratory and emancipatory purpose. Four young people with diagnoses of autism (three male, one female) aged between 18 and 22 years old, enrolled on further education training courses in two colleges in two different outer London boroughs, were recruited to the study. A qualitative methodology was used, involving a psycho-social method of data collection which comprised of individual interviews applying the free association Grid Elaboration Method (Joffe & Elsey, 2014) and thematic analysis of the data. Each participant was interviewed about their experiences of transition. Interview transcripts were analysed using thematic analysis following guidance from Braun and Clarke (2006). Researcher field notes were used to support the analysis. Six themes emerged from the data: Resilience, Growth and Development, Relationships, Mental Wellbeing, Agency and Understanding Difference. Strengths and limitations of the study, in addition to further applied implications of the findings for professionals working with young adults with autism, were identified. The study highlighted the importance of eliciting the views of young people with autism in order to facilitate positive transition experiences, which are likely to influence future outcomes for young people with autism
Evidence-based practice in educational and child psychology: Opportunities for practitioner-researchers using problem-based methodology
No full textAim: This paper proposes that certain interpretations of evidence-based practice contribute to a research-practice gap in Educational and Child Psychology [ECP]. It critically analyses one methodology – Problem Based Methodology [PBM] - that may help narrow such a gap. Rationale: Evidence-based practice is sometimes perceived as the use in applied practice of the best available research evidence, almost to the exclusion of practitioner expertise and client preferences. There is even less acknowledgement of how applied psychologists effectively integrate research, clinical judgment and client choice in applied practice contexts. Research methodologies that support practitioner-researchers with decision-making processes undertaken in complex human systems may therefore have significant advantages. In particular, those undertaking research for the purpose of enhancing practice, often an aim of ECP enquiry, may benefit from utilising methodologies that are well matched to the nature of applied practice. Findings: Problem Based Methodology is an approach to systematically researching applied practice with the explicit purpose of improving it. PBM advocates active discovery of and engagement with an individual's thinking, reasoning and decision-making [referred to as their Theory of Action]. In this paper, the epistemological and theoretical bases of PBM are outlined and empirical studies that have employed it are briefly described. An example of research on client outcomes in integrated early intervention contexts is discussed to illustrate the rich learning that comes from using PBM. Conclusions: The paper concludes with some suggestions for future developments in PBM
Present without past: The disruption of temporal integration in a case of transsexuality
No full textIn this article, I examine the impact of extensive modification of the body on thetemporal link, which is an important feature of human identity, as it provides continuity between different representations of the self over time. I illustrate this with a case of a young boy who underwent sex reassignment surgery in late adolescence after the artificial suspension of puberty through sex hormones. I argue that when hormones are used in this way, one can observe in some cases not only the desired suspension of physical time during which the body’s given biological trajectory is artificially halted, but also of psychological time. In some instances, this biological and psychic detour can result in a marked distortion in the young person’s relationship to time and impacts on their psychological adaptation following surgery