The role of group decision making processes in the creation of clinical guidelines

Guideline development groups are an integral part of evidence-based healthcare and will remain so for the foreseeable future. There is a need for the efficient production of high-quality guidelines both to ensure high standards of care and to conserve resources. Social psychological research on group processes provides valuable information that can be applied to studying the functioning of guideline development groups, including the methods they use to develop recommendations. This article describes four key concepts in the group process literature: information sharing, systematic processing, group development, and group potential productivity. We evaluate their importance for guideline development groups and conclude with methodological suggestions for the study of these complex processes.     

Korean Clinical Practice Guideline for the Diagnosis and Treatment of Insomnia in Adults

Objective We aim to present a clinical guideline for the diagnosis and treatment of insomnia in adults by reviewing and integrating existing clinical guidelines. The purpose of this guideline is to assist clinicians who perform evidence-based insomnia treatment. Methods We selected literature that may be appropriate for use in guideline development from evidence-based practice guidelines that have been issued by an academic or governmental institution within the last five years. The core question of this guideline was made in sentence form including Patient/Problem, Intervention, Comparison, Outcome (PICO) elements. After searching PubMed, EMBASE, and medical guideline issuing agencies, three guidelines were judged to be the most appropriately reviewed, up-to-date, and from trusted sources. Results The Appraisal of Guidelines for Research and Evaluation (AGREE) II tool was used to evaluate the quality of the three clinical guidelines. The final outcome of the guideline development process is a total of 15 recommendations that report the strength of the recommendation, the quality of evidence, a summary of content, and considerations in applying the recommendation. Conclusion It is vital for clinical guidelines for insomnia to be developed and continually updated in order to provide more accurate evidence-based treatments to patients.     

From feelings of imprisonment to group cohesion: A qualitative analysis of group analytic psychotherapy with dual diagnosed patients admitted to an acute inpatient psychiatric unit

Objectives: Group cohesion, the establishment of hope, and the expression of feelings have been said to be the basic ingredients of group psychotherapy. To date, there is few literature describing therapeutic processes in short stay settings such as acute psychiatric wards and with special patient groups such as addictions. Our goal with this study is to describe and analyze group processes in such contexts. Methods: We used a qualitative methodology combining constant comparative methods and hermeneutical triangulation to analyze therapeutic narratives in the context of a group analytic process carried following Foulkes’ and Yalom’s styles. Results: The results provide a picture of the therapeutic process including the use of norms to strengthen group cohesion facilitating the expression of emotions in early stages of group development. Conclusions: This analysis is intended to be a guide for practitioners implementing group therapy in contexts involving several constraints, such as acute psychiatric wards.     

Service user involvement in clinical guideline development and implementation: Learning from mental health service users in the UK

Abstract

The participation of service users and the public in the development of clinical guidelines is increasingly valued in international guideline programmes. This paper extends the findings of Harding et al.'s (2010) exploration of the views of service users who participated in developing NICE mental health guidelines. This analysis considered the relative value of personal versus professional knowledge and experience, the barriers to service users contributing effectively in guideline development, the unspoken ‘rules’ concerning decision making, and issues of power and group dynamics. We combine these insights with observations from research in guideline development and with advances in the recovery movement and in the shared decision-making clinical model to suggest areas of improvement in guideline development, notably: translating evidence to recommendations, optimizing the acceptability of treatment recommendations to service users, and reconciling different types of knowledge.     

The CARE-AAT Guideline: Development and testing of a consensus-based guideline for case reports in anthroposophic art therapy

ABSTRACT

Anthroposophic art therapists (AATs) report individual cases in narratives of poor scientific quality. Good quality case reports are an important factor in the development of evidence-based practice. A guideline for scientific case reports could contribute to this. However, the recently published guideline for medical case reports (the CARE Guidelines, covering diagnosis, treatment and outcomes) is not completely suitable for AAT. This study aimed at the development of a guideline for AAT case reports. The CARE Guidelines were adjusted following the recommended steps for health reporting guidelines. The proposed adjustments are based on AAT literature and expert opinions. The face validity of the new CARE-AAT Guideline was judged by an international group of 35 AATs and 3 experts on case study methodology. Seven items of the CARE Guidelines needed specification or addition. One item (Treatment Objectives and Plan) had to be added and six items could be used without change. The face validity of the new guideline is good. The CARE-AAT Guideline is suitable for scientific case reporting of AAT practice. It is assumed to be suitable for art therapy case reporting as well. Future use of the guideline will show whether further optimisation of the guideline is needed.     

Intrusive images and voluntary memory for affective pictures: Contextualization and dual-task interference

Background and objectivesThe present study addressed the role of context information and dual-task interference during the encoding of negative pictures on intrusion development and voluntary recall.MethodsHealthy participants were shown negative pictures with or without context information. Pictures were either viewed alone or concurrently with a visuospatial or verbal task. Participants reported their intrusive images of the pictures in a diary. At follow-up, perceptual and contextual memory was tested.ResultsParticipants in the context group reported more intrusive images and perceptual voluntary memory than participants in the no context group. No effects of the concurrent tasks were found on intrusive image frequency, but perceptual and contextual memory was affected according to the cognitive load of the task.LimitationsThe analogue method cannot be generalized to real-life trauma and the secondary tasks may differ in cognitive load.ConclusionsThe findings challenge a dual memory model of PTSD but support an account in which retrieval strategy, rather than encoding processes, accounts for the experience of involuntary versus voluntary recall.     

Establishment of a clinician-led guideline on the diagnosis and treatment of Hirayama disease using a modified Delphi technique

ObjectiveTo establish a clinician-led guideline for the diagnosis and treatment of Hirayama disease (HD) using a modified Delphi technique.MethodsBased on a combination of a systematic review and opinion of ten experts, a protocol for the consensus of the diagnosis, treatment and follow-up assessment of HD was established. A modified 3-round Delphi survey was then performed by more than 40 panelists from various countries of the world. Both levels of evidence and levels of agreement were derived in all statements of finial guideline.ResultsA total of 47 experts from 6 countries were enrolled in the expert panel in this study. Highly consistent results were achieved during the three Delphi rounds. An expert-led guideline finally constructed includes 24 statements related to diagnosis, treatment and follow-up assessment of HD.ConclusionsThe modified Delphi technique used in this study resulted in an expert-led guideline concerning several clinical aspects of HD.SignificanceThis clinician-led guideline may provide a helpful direction for clinical practice with regard to the diagnosis and treatment of HD.     

Memory bias for health-related information in somatoform disorders

ObjectiveCognitive processes are considered to be relevant to the etiology and maintenance of somatoform disorders (SFDs). The aim of this study was to assess explicit and implicit information-processing bias for disorder-congruent information in SFDs.MethodsA clinical sample of 33 patients suffering from multiple somatoform symptoms (SSI-3/5) and 25 healthy controls performed an encoding task with computer-presented word lists (illness related, negative, positive, neutral content), subsequently followed by explicit memory tests (free recall and recognition) and an implicit test (word-stem completion).ResultsThe somatoform group showed a memory bias for illness-related stimuli in the word-stem completion task, whereas the two groups did not differ in explicit memory tests. This effect could not be explained by comorbid depression.ConclusionThese results provide some support for current theories on SFDs.     

Assessment of transcultural psychotherapy to treat resistant major depressive disorder in children and adolescents from migrant families: Protocol for a randomized controlled trial using mixed method and Bayesian approaches

ObjectivesCultural variations complicate psychiatric care, especially for migrant children. Transcultural psychotherapy (TCP) is an original psychotherapeutic technique developed to address complex situations of resistant mental disorders in the context of migration. This research will aim to assess the efficacy, the acceptability, and describe the therapeutic processes of TCP for the treatment of depression in first or second generation of migration children and adolescents.MethodMixed method study using a multicenter, Bayesian randomized clinical trial with blinded evaluation of the primary outcome. Two parallel groups of 40 children or adolescents from 6 to 20 years old and their family will be included. In the experimental group, patients will attend six sessions of transcultural therapy in addition to usual care.ResultsThe improved Clinical Global Impression scale scores at 6 months will be compared across groups. Qualitative analysis of families and therapists'' interviews will allow to specify the therapeutic processes and acceptability of the therapy.ConclusionThe findings will encourage the development and routinization of TCP for second‐line use and its adaption as a first‐line technique in this population.     

A comparison of UK and US guidelines for drug treatment in borderline personality disorder

Abstract

The UK and USA differ considerably in their guidance regarding the use of drug treatment for borderline personality disorder, but generally agree over the use of psychological treatment. The 2009 UK guidelines from the National Institute for Health and Clinical Excellence (NICE) do not recommend any form of drug treatment except in a crisis with the intention of ceasing such treatment shortly afterwards. The US guidelines from the American Psychiatric Association (APA), published in 2001, are much more positive and suggest that there is a place for selective serotonin reuptake inhibitors (SSRIs), mood stabilizers and antipsychotic drugs as adjunctive treatments in borderline personality disorder. The guidelines are summarized and two main reasons for the differences identified. First, the separation of the borderline personality group into those with ‘affective dysregulation’, ‘impulsive behaviour dyscontrol’ and ‘cognitive–perceptual’ symptoms in the US guidelines was felt by the guideline development group for the NICE guideline to be a post hoc classification not supported by any other evidence. Second, the threshold of evidence necessary for making recommendations was much higher for the UK than the US guideline. Both guidelines recognize that we need more substantial trials, preferably independent of the pharmaceutical industry, before we can have any real confidence in our recommendations.     

Knowledge acquisition and research evidence in autism: Researcher and practitioner perspectives and engagement

BackgroundGovernment policy and national practice guidelines have created an increasing need for autism services to adopt an evidence-based practice approach. However, a gap continues to exist between research evidence and its application. This study investigated the difference between autism researchers and practitioners in their methods of acquiring knowledge.MethodsIn a questionnaire study, 261 practitioners and 422 researchers reported on the methods they use and perceive to be beneficial for increasing research access and knowledge. They also reported on their level of engagement with members of the other professional community.ResultsResearchers and practitioners reported different methods used to access information. Each group, however, had similar overall priorities regarding access to research information. While researchers endorsed the use of academic journals significantly more often than practitioners, both groups included academic journals in their top three choices. The groups differed in the levels of engagement they reported; researchers indicated they were more engaged with practitioners than vice versa.ConclusionsComparison of researcher and practitioner preferences led to several recommendations to improve knowledge sharing and translation, including enhancing access to original research publications, facilitating informal networking opportunities and the development of proposals for the inclusion of practitioners throughout the research process.     

Effects of closed-head injury on attentional processes: An information-processing stage analysis

Abstract

The present study, based on Sternberg's (1969) additive-factor method, examined attentional processes in terms of four information-processing stages (feature extraction, identification, response selection, and motor adjustment). Four task variables were used to operationally define the stages (signal quality, signal similarity, signal-response compatibility, and foreperiod uncertainty). In two studies, a visuo-spatial reaction-time task was undertaken by a group of university subjects (Experiment 1) and by three groups of closed-head-injured patients (severe short-term, severe long-term, and mild short-term) and their corresponding matched controls (Experiment 2). The results indicated that both patients and normals exhibited a similar mode of linear information processing. In addition, it was found that the severe short-term group was impaired on the response-selection stage and response selection stage; the severe long-term group was impaired only on the response-selection; and no evidence of impairment was found for the mild short-term patients. The implications of these findings with reference to the study of attentional processes in closed-head injured patients and to neuropsychological assessment and rehabilitation are discussed.     

Physical activity,activity change,and their correlates in a population-based sample of colorectal cancer survivors

Background: Physical activity can provide benefits to cancer survivors, including reduced symptoms and treatment side effects, improved overall quality of life, and decreased risk of other chronic diseases.Purpose: The aim of the study was to describe physical activity before and after diagnosis of colorectal cancer and to examine the associations with sociodemographic and disease-related variables.Methods: Telephone interviews were conducted with 1,996 colorectal cancer survivors recruited through a cancer registry.Results: In comparison to prediagnosis activity levels, there were 21% fewer participants meeting the physical activity and health guideline (150 min of moderate-intensity physical activity per week) postdiagnosis. Meeting the guideline postdiagnosis was associated with being male, living outside of the state capital city, having a higher education, having a healthy body mass index, not smoking, having had surgery only, and no reported fatigue. Attributes associated with a decrease in physical activity following diagnosis were being female, living within the state capital city, having a lower level of education, having a stoma, having adjuvant therapy, and experiencing fatigue.Conclusions: There is considerable scope for targeted interventions to increase the physical activity of colorectal cancer survivors, particularly for those groups that we have identified as being less active and/or have reduced their activity. This project was funded by The Cancer Council Queensland. We acknowledge Mrs Monica West for her contribution to the data collection.     

Direct and indirect measures of context in patients with mild-to-severe traumatic brain injury (TBI): The additive contribution of eye tracking

Introduction: The facilitation of memory for target stimuli due to the similarity of context in the learning and testing phases is known as the “Context-Effect” (CE). Previous studies reported that TBI affects memory for contextual information when tested directly. However, the indirect effect of contextual information on memory of target (i.e., CE) is preserved. Several studies have demonstrated that CE is composed of multiple, distinct cognitive processes. The present study includes four context conditions to enable identification of the exact process affected by TBI. In addition, eye movements were monitored to test three hypotheses: first, that the TBI group’s dwell time on target (DTOT) at encoding would be less than that of controls. Second, that DTOT at encoding would be more highly associated with recognition at test for the control group than for the TBI group. Third, that overall DTOT at encoding on new, as compared to old items (“repetition effect”), would be less pronounced for the TBI group as compared to controls.

Methods: Twenty-four patients with mild-to-severe TBI and 23 matched controls participated in this study. We presented participants with photographs of male faces shown wearing distinctive, trial-unique hats (yielding specific Target-Context pairing). Eye movements were recorded throughout the test task.

Results: Memory for faces following TBI is impaired compared to that of controls. The magnitude and pattern of CE are the same for both groups. The TBI group has a lower DTOT compared to that of controls. However, the relative length of DTOT in the various conditions is similar in both groups.

Conclusions: Behavioral results indicate that although the TBI group has impaired memory for faces, the CE pattern is similar to that of controls. Similarly, in terms of eye movements, although the TBI group focuses less on target, relations between the various conditions are similar in both groups.     

Collaborative design of accessible information with people with aphasia

ABSTRACT

Background: People with aphasia report preferences for specially formatted health information materials, but there is little evidence that modified materials result in improved comprehension. Potential explanations for this include language included not taking account of aphasic processing difficulties, topics unrelated to aphasia, lack of clarity regarding the use of images, and the lack of end-user involvement in the design. Additionally, no definitive criteria for production of accessible information have been identified.

Aims: The first aim of this study was to collaborate with people with aphasia in an iterative design process to develop and finalise accessible information materials. The second aim was to identify definitive criteria for use in the future production of information materials for people with aphasia.

Methods and procedure: Prototype materials were developed for the study, based on criteria identified from the existing research into aphasia-accessible information, and on the evidence base concerning language processing in aphasia. Fourteen people with aphasia took part in two rounds of consensus group meetings and viewed information about aphasia presented within the prototype materials. Consensus points were identified within the groups through discussion and through ratings using Likert scales. The set of consensus points and ratings were adapted into criteria for graphic designers to incorporate into subsequent designs of the materials, in order to generate a final version, and related criteria.

Outcomes and results: The group discussions and the ratings of materials led to the identification of an agreed layout within which to present information, and specific criteria for the following: information consisting of one proposition expressed via everyday words and canonical syntactic forms; one or two images relating directly to keywords; sans serif typography with keyword emphasis. Individual preferences with regard to image types were identified. Novel criteria were identified in the study, relating to layout, language, images and typography. These were added to the original set of criteria to form definitive criteria for use in the development of accessible aphasia materials.

Conclusions: This study successfully involved people with aphasia in the design process to produce novel materials, and related design criteria. The resulting materials and criteria differ from those previously proposed, by reflecting directly people with aphasia’s views and preferences, and by incorporating language and images suitable for people with aphasia, based on the existing research evidence and the outcomes of this study. The materials and criteria have the potential to improve people with aphasia’s understanding of health information.     

South African English Speech Development: Preliminary Data from Typically Developing Preschool Children in Cape Town

ABSTRACT

English is one of eleven official languages in South Africa, but there is limited information on children’s acquisition of English and other languages in this context. This paper describes speech development in 308 children aged 3;0–5;11 acquiring South African English in Cape Town. The study focused on English speech acquisition, although children were grouped by language background into monolingual, isiXhosa bilingual, Afrikaans bilingual and trilingual groups. The primary objective was to describe phonetic and phonological acquisition (percentage consonants and vowels correct (PCC and PVC); phonetic inventory and phonological processes) by children’s age and language background. As a secondary objective we described the prevalence of speech disorders in the sample using Dodd’s (2005) framework. The Diagnostic Evaluation of Articulation and Phonology was used to assess participants with modified scoring criteria appropriate for the context. Phonological processes and inventories were broadly comparable to normative data for English speech acquisition documented in the literature, and a progression was observed with increasing age. PCC and PVC were similar for children within age bands despite different language backgrounds. Bilingual children showed aspects of English phonological development linked to their L1, and some differences in phonological processes were observed. Approximately 9% of children (n = 28) had speech difficulties, with 75% of this group having a speech delay. The study highlights the importance of adapting speech assessments for use with populations that differ from the originally intended audience. This work contributes to knowledge of typical speech development in South Africa and in multilingual contexts more generally.     

Dissociation of preparatory attention and response monitoring maturation during adolescence

ObjectiveSubstantial brain development occurs during adolescence providing the foundation for functional advancement from stimulus-bound “bottom-up” to more mature executive-driven “top-down” processing strategies. The objective was to assess development of EEG markers of these strategies and their role in both preparatory attention (contingent negative variation, CNV) and response monitoring (Error Related Negativity, ERN, and Correct Related Negativity, CRN).MethodsCNV, ERN and CRN were assessed in 38 adolescents (18 girls), age 11–18 years, using a variation of a letter discrimination task.ResultsAccuracy increased with age and developmental stage. Younger adolescents used a posterior attention network involved in inhibiting irrelevant information. Activity in this juvenile network, as indexed by a posteriorly-biased CNV and CRN decreased with age and advancing pubertal development. Although enhanced frontal CNV, known to be predictive of accuracy in adults, was not detected even in the older adolescents, top-down medial frontal response monitoring processes (ERN) showed evidence of development within the age-range studied.ConclusionsThe data revealed a dissociation of developmental progress, marked by relatively delayed onset of frontal preparatory attention relative to error monitoring.SignificanceThis dissociation may render adolescents vulnerable to excessive risk-taking and disinhibited behavior imposed by asynchronous development of component cognitive control processes.     

Sleep patterns in preschool-age children with autism, developmental delay, and typical development

ObjectiveA prominent noncore symptom of autistic disorder is disturbed sleep, but relatively few studies have investigated this symptom.MethodA multimethod approach assessed the quantity and quality of sleep in 194 children (68 with autism [AUT], 57 with developmental delay without autism [DD], 69 with typical development) recorded over 1 week. Parent perceptions, structured questionnaires, and actigraphy were compared. In addition, problem sleep as defined by parents was compared with research diagnostic criteria for behavioral insomnia obtained from actigraph recordings.ResultsOn actigraphy, children in the DD group, after sleep onset, exhibited more and longer awakenings than the other two groups. In contrast, children in the AUT group exhibited less total sleep time in 24 hours than the other two groups. Parent reports of sleep problems were higher in the AUT and DD groups than the typical development group, but parent reports did not concur with more objective RDC for behavioral insomnia. Parent reports of sleep problems in all of the groups were significantly associated with increased self-reports of stress. Total 24-hour sleep durations for all of the groups were shorter than recommended for preschool-age children.ConclusionsOur study provides objective evidence that sleep patterns are different in preschool children across the categories of AUT, DD, or typical development. J. Am. Acad. Child Adolesc. Psychiatry, 2008;47(8):930-938.