Background: The transition to child care is a challenging time in a child’s life and leads to elevated levels of cortisol. These elevations may be influenced by the quality of the mother-child-relationship. However, remarkably little is known about cortisol production in response to the beginning of child care among children-at-risk such as children with an immigrant background. However, attending kindergarten or any other child day-care institution can for example have a compensating effect on potential language deficits thus improving (...) the educational opportunities of these children. Method: Data of a subsample of N = 24 “hard-to-reach” mother-child dyads was collected in the context of the psychoanalytic early prevention project “First Steps”. The project focuses on the earliest integration of children with an immigrant background by supporting parenting capacities in the critical phase of migration and early parenthood. Children’s hair cortisol concentration (HCC) was assessed one week before (mean age = 38.77 months) and three months after kindergarten entry (mean age = 42.26 months). Hair analysis was conducted for both times of measurement, reflecting the first 3 months after kindergarten entry and 3 months prior. Furthermore, the emotional quality of the mother-child-relationship was assessed with the help of the Emotional Availability Scales (EAS) shortly before kindergarten entry when the children were about three years old (mean age = 37.2). Results and Conclusion: Children’s mean cumulated HCC was higher after kindergarten entry than before. The increase correlated negatively with several dimensions of the EAS. Repeated measures ANCOVA revealed that particularly responsive children and children who had experienced less intrusive mother-child-relationships demonstrated lower elevations in HCC after kindergarten entry. Furthermore, a decreased EA score was found in all EA dimensions, besides the dimension “mother’s non-hostility”, indicating problematic EA within the mother-child-relationships of the sample. The results suggest that children with an immigrant background who experience more emotional available mother-child-relationships seem to regulate stress induced by kindergarten entry more effectively, indicated by lower cortisol elevations after entry. This implicates that supporting early mother-child-relationships by intervention may have a positive effect on the children’s ability to regulate stress induced by kindergarten entry thus promoting child development. (shrink)

Current research suggests that stressful life experiences and situations create a substantive effect in the development of the initial manifestations of psychotic disorders and may influence temporo-limbic epileptic-like activity manifesting as cognitive and affective seizure-like symptoms in non-epileptic conditions. The current study assessed trauma history, hair cortisol levels, epileptic-like manifestations and other psychopathological symptoms in 56 drug naive adult young women experiencing their initial occurrence of psychosis. Hair cortisol levels among patients experiencing their initial episode of (...) psychosis, were significantly correlated with stress symptoms measured by Trauma Symptom Checklist-40, and complex partial seizure-like symptoms measured by the Complex Partial Seizure-Like Symptoms Inventory and LSCL-33. Hair cortisol levels were not found to be significantly correlated with symptoms of anxiety and depression measured by Beck depression Inventory and Zung Anxiety Scale. These findings suggest a significant relationship between epileptic-like symptoms and stress responses demonstrated by patients in their first psychotic episode. These findings may suggest the potential for research to explore usefulness of anticonvulsant treatment in patients who do not respond to usual psychotropic medication. (shrink)

Psychobiological responses to music have been examined previously in various naturalistic settings in adults. Choir singing seems to be associated with positive psychobiological outcomes in adults. However, evidence on the effectiveness of singing in children and adolescents is sparse. The COVID-19 outbreak is significantly affecting society now and in the future, including how individuals engage with music. The COVID-19 pandemic is occurring at a time when virtual participation in musical experiences such as singing in a virtual choir has become more (...) prevalent. However, it remains unclear whether virtual singing leads to different responses in comparison with in-person singing. We evaluated the psychobiological effects of in-person choral singing in comparison with the effects of virtual choral singing in a naturalistic pilot within-subject study. A group of children and young adolescents from a school in Salzburg, Austria were recruited to take part in the study. Subjective measures were taken pre- and post-singing sessions once a week. Additionally, salivary biomarkers and quantity of social contacts were assessed pre- and post-singing sessions every second week. Psychological stability, self-esteem, emotional competences, and chronic stress levels were measured at the beginning of in-person singing as well as at the beginning and the end of the virtual singing. We observed a positive impact on mood after both in-person and virtual singing. Over time, in-person singing showed a pre-post decrease in salivary cortisol, while virtual singing showed a moderate increase. Moreover, a greater reduction in stress, positive change in calmness, and higher values of social contacts could be observed for the in-person setting compared to the virtual one. In addition, we observed positive changes in psychological stability, maladaptive emotional competences, chronic stress levels, hair cortisol, self-contingency and quality of life. Our preliminary findings suggest that group singing may provide benefits for children and adolescents. In-person singing in particular seems to have a stronger psychobiological effect. (shrink)

Robert Preece’s The Psychology of Buddhist Tantra and Khenchen Thrangu Rinpoche’s Everyday Consciousness and Primordial Awareness are reviewed. Both books address Tibetan Buddhism, and their common threads underscore this discussion. Even when separated from their original contexts, the Tibetan Buddhist teachings offer understandings about a common human nature and a method of transforming consciousness through awareness.

The successful demonstration that antiretroviral (ARV) drugs can be used in diverse ways to reduce HIV acquisition or transmission risks – either taken as pre-exposure prophylaxis (PrEP) by those who are uninfected or as early treatment for prevention (T4P) by those living with HIV – expands the armamentarium of existing HIV prevention tools. These findings have implications for the design of future HIV prevention research trials. With the advent of multiple effective HIV prevention tools, discussions about the ethics and the (...) feasibility of future HIV prevention trial designs have intensified. This article outlines arguments concerning the inclusion of newly established ARV-based HIV prevention interventions as standard of prevention in HIV prevention trials from multiple perspectives. Ultimately, there is a clear need to incorporate stakeholders in a robust discussion to determine the appropriate trial design for each study population. (shrink)

In clinical research there is a tension between the role of a doctor, who must serve the best interests of the patient, and the role of the researcher, who must produce knowledge that may not have any immediate benefits for the research participant. This tension is exacerbated in HIV research in low and middle income countries, which frequently uncovers comorbidities other than the condition under study. Some bioethicists argue that as the goals of medicine and those of research are distinct, (...) it is a mistake for researchers to assume therapeutic responsibilities while engaging in research. Others propose that there is a duty of care, but disagree as to how this is limited and specified. In this qualitative study, principal investigators from HIV prevention trials discuss their experience of providing medical benefits to participants within the context of conducting research into HIV biomedical prevention technologies. They describe the limitations imposed at times by funders and at times by infrastructure constraints, and canvass the importance of ancillary care provision and capacity building in trial communities. The views of the principal investigators are compatible with the perspective that there is a duty of care, limited by the nature of the research, the depth of the relationship between research and participant, and the capacity of the research site. The therapeutic orientation in HIV prevention trial appears to be indivisible from competent research practise by making concrete and appropriate benefits available to trial participants and their communities that support rather than compete with local infrastructure. (shrink)

Vaccination is a highly effective public health strategy that provides protection to both individuals and communities from a range of infectious diseases. Governments monitor vaccination rates carefully, as widespread use of a vaccine within a population is required to extend protection to the general population through “herd immunity,” which is important for protecting infants who are not yet fully vaccinated and others who are unable to undergo vaccination for medical or other reasons. Australia is unique in employing financial incentives to (...) increase vaccination uptake, mainly in the form of various childcare payments and tax benefits linked to timely, age-appropriate vaccination. Despite relatively high compliance with the childhood vaccination schedule, however, the Australian government has determined that rates should be higher and has recently introduced policy that includes removing certain tax and childcare benefits for non-vaccinators and formally disallowing conscientious objection to vaccination. In addition, it has raised the possibility of banning unvaccinated children from childcare centres. This article examines the impact of coercive approaches to childhood vaccination and raises the question of the ethical justification of health policy initiatives based on coercion. We consider the current evidence regarding childhood vaccination in Australia, the small but real risks associated with vaccination, the ethical requirement for consent for medical procedures, and the potential social harms of targeting non-vaccinators. We conclude that the evidence does not support a move to an increasingly mandatory approach that could only be delivered through paternalistic, coercive clinical practices. (shrink)

Volume 20, Issue 10, October 2020, Page 47-49.

In 2010, randomized controlled trials (RCTs) of two different biomedical strategies to prevent HIV infection had positive findings. However, despite ongoing very high levels of HIV infection in some countries and population groups, it has been made clear by regulatory authorities that the evidence remains insufficient to support either product being made available outside of research contexts in the developing world for at least two years. In addition, prevention trials in endemic areas will continue to test new interventions against placebo. (...) But the judgments of evidentiary standards are never value-neutral. Using the recent trials and their contexts as case studies, we examine the basis for these decisions, which will potentially delay access to scientific innovation to the people who are most urgently in need of it. (shrink)

The principle of providing post-trial access for research participants to successful products of that research is widely accepted and has been enshrined in various declarations and guidelines. While recent ethical guidelines recognise that the responsibility to provide post-trial access extends to sponsors, regulators and government bodies as well as to researchers, it is the researchers who have the direct duty of care to participants. Researchers may thus need to act as advocates for trial participants, especially where government bodies, sponsors, and (...) regulatory bodies have complex interests vested in decisions about whether or not new interventions are made available, how, and to whom. This paper provides an empirical account of post-trial access in the context of HIV prevention research. It describes both access to the successful products of research and the provision antiretroviral drugs for trial participants who acquire HIV. First, we provide evidence that, in the current system, there is considerable variation in the duration and timeliness of access. We then argue that by analysing the difficulties faced by researchers to this point, and their efforts to meet this obligation, much can be learned about how to secure post-trial access in HIV biomedical preventions trials. While researchers alone have a limited obligation, their advocacy on behalf of trial participants may be necessary to call the other parties to account. (shrink)

Published data show that new HIV prevention strategies including treatment-as-prevention and pre-exposure prophylaxis (PrEP) using oral antiretroviral drugs (ARVs) are highly, but not completely, effective if regimens are taken as directed. Consequently, their implementation may challenge norms around HIV prevention. Specific concerns include the potential for ARV-based prevention to reframe responsibility, erode beneficial sexual norms and waste resources. This paper explores what rights claims uninfected people can make for access to ARVs for prevention, and whether moral claims justify the provision (...) of ARV therapy to those who do not yet clinically require treatment as a way of reducing HIV transmission risk. An ethical analysis was conducted of the two strategies, PrEP and treatment-as-prevention, using a public health stewardship model developed by the Nuffield Bioethics Council to consider and compare the application of PrEP and treatment-as-prevention strategies. We found that treating the person with HIV rather than the uninfected person offers advantages in settings where there are limited opportunities to access care. A treatment-as-prevention strategy that places all the emphasis upon the positive person's adherence however carries a disproportionate burden of responsibility. PrEP remains an important option for receptive partners who face increased biological vulnerability. We conclude that the use of ARV for prevention is ethically justified, despite imperfect global to drugs for those in clinical need. The determination of which ARV-based HIV prevention strategy is ethically preferable is complex and must take into account both public health and interpersonal considerations. (shrink)

This paper exposes the relation between the different mathematical orientations, on the one hand, and the modes of documentary film on the other. When we take, with Badiou, mathematics as ontology, and mathematical orientations as orientations to Being, we find in the structural similarity of mathematics and documentary an equivalence: between modes of documentaryand mathematical-ontological decisions, regarding the inscription of 'what is'. From here we move to consider Badiou's notion of 'in-appearing' through a reading of Alain Resnais' documentary Night and (...) Fog. (shrink)

This study investigated patient preferences for various types of physician persuasion strategies. Four types of persuasion strategies were utilized which involved combination of high and low levels of affectivity and information. In addition, patient variables, receiver apprehension and health beliefs were introduced to predict preference choices by patients. Results indicated that patients are influenced in their decision-making (preferences) by the type of persuasive strategy employed. Further, patients with different characteristics and predispositions prefer different persuasive strategies. The results of this study (...) suggest that the success of physician persuasiveness is dependent upon the type of strategy used and the type of patient being persuaded. (shrink)

The American Journal of Bioethics, Volume 11, Issue 12, Page 48-50, December 2011.

In many countries around the world, people who inject drugs remain at high risk of HIV acquisition not because effective forms of prevention are unknown, nor because they find effective prevention undesirable, but because those in charge, mainly politicians but also bureaucrats, find evidence-based practice politically unacceptable. The evidence for preventive efficacy of harm reduction strategies, most prominently needle and syringe programmes but also treatment programmes such as opiate substitution, is irrefutable.1 However, political responses to drug use issues are varied (...) and complex, so the will to implement appropriate harm reduction programmes in the interests of public health remains lacking in too many jurisdictions. As a consequence, the discussion of how best, in the context of research, to reduce HIV incidence in populations of people who inject drugs but are not offered comprehensive access to known prevention strategies is—tragically—an important one. Dawson et al 2 focus on access to sterile injecting equipment and recognise that this should remain the ‘default’ standard of prevention for HIV prevention trials involving people for whom injecting drug use is the primary risk factor for HIV acquisition. ‘Standard of prevention’ means the background or minimal HIV risk reduction interventions offered to all participants in a trial, regardless of what other investigational interventions they are assigned to receive. The standard of prevention concept is grounded in the ethical principle of beneficence—that researchers and sponsors are obliged to maximise benefits and minimise risks to participants in research studies.3 …. (shrink)

This article examines the relationship between bioethics and the therapeutic standards in HIV prevention research in the developing world, focusing on the closure of the pre-exposure prophylaxis (PrEP) trials in the early 2000s. I situate the PrEP trials in the historical context of the vertical transmission debates of the 1990s, where there was protracted debate over the use of placebos despite the existence of a proven intervention. I then discuss the dramatic improvement in the clinical management of HIV and the (...) treatment access movement, and consider how these contexts have influenced research practice. I argue that as HIV prevention trials oblige researchers to observe the rate at which vulnerable people under their care acquire HIV, there is an obligation to provide antiretroviral treatment to seroconverters and other health care benefits that fall within the scope of researchers' entrustment, both to avoid exploitation and to enact reciprocal justice. I argue against propositions that the obligations to provide specific benefits are vague, fall only upon researchers and sponsors, and create injustices by privileging the few over the many. Finally, I contend that the realisation of a broader standard of care in HIV prevention research broadens the role of research from being a simple tool to produce knowledge to a complex intervention that can play a part in the reduction of health disparities. (shrink)

In July 2012, based on evidence from two major trials, the United States Food and Drug Administration approved the use of combined oral tenofovir/emtricitabine as pre-exposure prophylaxis for people at high risk of HIV acquisition. PrEP effectiveness is marred by poor adherence, however, even in trial populations, thus it is not a magic bullet for HIV prevention. It is, however, the most effective biomedical HIV prevention intervention available for people at high risk of HIV, particularly those who have receptive sex (...) and lack the power to negotiate condom use. Accordingly, there are compelling reasons to compare future experimental HIV prevention interventions against PrEP. The interests both of trial participants and of science are served by using PrEP as comparator: Not only would HIV incidence be reduced, but also the question of whether new interventions were superior to best proven interventions, in a given setting, would be answered comprehensively. (shrink)

In his article ‘The Ebola Clinical Trials: a precedent for research ethics in disasters’, Philippe Calain constructs a compelling case as to why and how experiences from the recent Ebola epidemic should be used to develop a framework for disaster research ethics. In particular, Calain proposes a useful model for assessing whether or not an unproven intervention could be suitable for human use in a disaster context, and makes a powerful argument against the separation of patient care from research goals. (...) In this commentary, I argue that the separation of patient care goals from research goals is also unhelpful in the context of other forms of participant disadvantage even when that disadvantage is less severe than an ongoing public health emergency. I contend that recognising that research in disadvantaged populations is an intervention that could and should aim to produce positive outcomes for participants, just as it should in disaster contexts, therefore seems a well-justified lesson that can be extrapolated from the experience of the Ebola epidemic. (shrink)

Qu'est-ce que la philosophie? Cette question simple ne devrait pas poser de véritables difficultés puisque nous utilisons régulièrement le mot ainsi que ceux de même famille. Mais une fois que l'on a rappelé son origine grecque et son étymologie, beaucoup se trouvent embarrassés. Puisque la philosophie occidentale est née chez les Hellènes avant d'être transmise aux Romains, c'est en s'intéressant à cette longue période qui va de Thalès de Milet à Plotin que l'on pourra trouver une réponse. Au-delà des différences (...) d'écoles, pourquoi tous ces hommes se disent-ils philosophes? Au-delà de leurs querelles, pourquoi sont-ils d'accord pour affirmer qu'ils font de la philosophie? Qu'est-ce que la philosophie chez les pères de la philosophie? (shrink)

This chapter contains sections titled: “Christmas is here. Lovely, glorious, beautiful Christmas …” “Some men are Baptists, others Catholics; my father was an Oldsmobile man” “There it is, the ‘Holy Grail’ of Christmas presents …” “We plunged into the cornucopia quivering with desire and the ecstasy of unbridled avarice”.

In their recent paper‘Undue inducement: a case study in CAPRISA 008’, Mngadi et al conclude that a participant in an HIV prevention study who deliberately concealed her pregnancy was not ‘unduly induced’ to participate by the offer of an experimental product. This paper argues that while the authors’ conclusion is sound, the framing of this case study is consistent with the preoccupation in research ethics with the concept of undue inducement, coupled with a highly risk-averse attitude to pregnancy. We suggest (...) that the critical research ethics question raised by Mngadi et al ’s case study is not ‘undue inducement’, but the exclusion of pregnant women from research studies where the risks are acceptable to the potential participant, and benefits likely. We also suggest that current regulatory paradigms regarding pregnancy are both overly paternalistic and value the fetus over the mother. In order to ensure timely provision of new HIV prevention agents, we argue that there is a need for expeditious testing of proven effective agents in pregnancy, with due consideration given to situations where preliminary efficacy data exist but fall short of licensure standards. This requires a paradigm shift from researchers, funders, regulators and ethical review bodies towards practices that critically examine the legitimacy of the exclusion of pregnant women on a study-by-study basis. (shrink)

There is increasing interest in the need to address the ethical dilemmas related to the engagement of adolescents in sexual and reproductive health research. Research projects, including those that address issues related to STIs and HIV, adverse pregnancy outcomes, violence, and mental health, must be designed and implemented to address the needs of adolescents. Decisions on when an individual has adequate capacity to give consent for research most commonly use age as a surrogate rather than directly assessing capacity to understand (...) the issues and make an informed decision on whether to participate in research or not. There is a perception that adolescents participating in research are more likely to be coerced and may therefore not fully comprehend the risk they may be taking when engaging in research. This paper examines the various ethical issues that may impact stakeholders' decision making when considering engaging adolescents in SRH research in Nigeria. It makes a case for lowering the age of consent for adolescents. While some experts believe it is possible to extrapolate relevant information from adult research, studies on ethical aspects of adolescents' participation in research are still needed, especially in the field of sexual and reproductive health where there are often differences in knowledge, attitudes and practices compared to adults. The particular challenges of applying the fundamental principles of research ethics to adolescent research, especially research about sex and sexuality, will only become clear if more studies are conducted. (shrink)

(2013). A review of “Smith, Nicholas J. J., Logic: The Laws of Truth. Australasian Journal of Philosophy: Vol. 91, No. 3, pp. 629-629. doi: 10.1080/00048402.2013.794849.

Dental caries is the main oral health challenge for children in Nigeria. Concern about its negative impact makes screening for caries in children an attractive public health strategy. The ability to detect the preclinical phase of caries, the availability of screening tools with high accuracy, and the possibility of treatment before onset of clinical symptoms with significant cost and health benefits, makes it appropriate for screening. However in Nigeria, the poor availability of highly specific and sensitive screening tools, poor access (...) to oral health care and concerns with pre-screening consent, raise the question of the appropriateness of conducting screening programmes for children. We argue that a number of structural challenges associated with poor uptake of oral health care services need to be addressed before screening for caries can be considered ethically appropriate. These include facilitating access of children to quality oral health care and a systematic national approach to oral health impl... (shrink)

Background Visual atypicalities in autism spectrum disorder (ASD) are a well documented phenomenon, beginning as early as 2–6 months of age and manifesting in a significantly decreased attention to the eyes, direct gaze and socially salient information. Early emerging neurobiological deficits in perceiving social stimuli as rewarding or its active avoidance due to the anxiety it entails have been widely purported as potential reasons for this atypicality. Parallel research evidence also points to the significant benefits of animal presence for reducing (...) social anxiety and enhancing social interaction in children with autism. While atypicality in social attention in ASD has been widely substantiated, whether this atypicality persists equally across species types or is confined to humans has not been a key focus of research insofar. Methods We attempted a comprehensive examination of the differences in visual attention to static images of human and animal faces (40 images; 20 human faces and 20 animal faces) among children with ASD using an eye tracking paradigm. 44 children (ASD n = 21; TD n = 23) participated in the study (10,362 valid observations) across five regions of interest (left eye, right eye, eye region, face and screen). Results Results obtained revealed significantly greater social attention across human and animal stimuli in typical controls when compared to children with ASD. However in children with ASD, a significantly greater attention allocation was seen to animal faces and eye region and lesser attention to the animal mouth when compared to human faces, indicative of a clear attentional preference to socially salient regions of animal stimuli. The positive attentional bias toward animals was also seen in terms of a significantly greater visual attention to direct gaze in animal images. Conclusion Our results suggest the possibility that atypicalities in social attention in ASD may not be uniform across species. It adds to the current neural and biomarker evidence base of the potentially greater social reward processing and lesser social anxiety underlying animal stimuli as compared to human stimuli in children with ASD. (shrink)

The Oceania region is home to some of the world's most restrictive abortion laws, and there is evidence of Pacific Island women's reproductive oppression across several aspects of their reproductive lives, including in relation to contraceptive decision‐making, birthing, and fertility. In this paper we analyse documents from court cases in the Pacific Islands regarding the illegal procurement of abortion. We undertook inductive thematic analysis of documents from eighteen illegal abortion court cases from Pacific Island countries.Using the lens of reproductive justice, (...) we discuss the methods of abortion, the reported context of these abortions, and the ways in which these women and abortion were constructed in judges' summing up, judgements, or sentencing. Our analysis of these cases reveals layers of sexual and reproductive oppression experienced by these women that are related to colonialism, women's socioeconomic disadvantage, gendered violence, limited reproductive control, and the punitive consequences related to not performing gender appropriately. (shrink)

Visual research methods like photography and digital storytelling are increasingly used in health and social sciences research as participatory approaches that benefit participants, researchers, and audiences. Visual methods involve a number of additional ethical considerations such as using identifiable content and ownership of creative outputs. As such, ethics committees should use different assessment frameworks to consider research protocols with visual methods. Here, we outline the limitations of ethics committees in assessing projects with a visual focus and highlight the sparse knowledge (...) on how researchers respond when they encounter ethical challenges in the practice of visual research. We propose a situated approach in relation to visual methodologies that encompasses a negotiated, flexible approach, given that ethical issues usually emerge in relation to the specific contexts of individual research projects. Drawing on available literature and two case studies, we identify and reflect on nuanced ethical implications in visual research, like tensions between aesthetics and research validity. The case studies highlight strategies developed in-situ to address the challenges two researchers encountered when using visual research methods, illustrating that some practice implications are not necessarily addressed using established ethical clearance procedures. A situated approach can ensure that visual research remains ethical, engaging, and rigorous. (shrink)

Dog ownership is believed to benefit owner wellbeing but, contrary to popular belief, there is limited evidence to suggest that simply owning a dog is associated with improved mental health. This mixed-methods study investigates whether dog owners with stronger relationships with their dogs experience better mental health. Participants completed an online survey. Owners’ health was measured using the validated PROMIS questions regarding depression, anxiety, emotional support, and companionship. The dog–owner relationship was measured using the validated MDORS scale, which has three (...) subscales: interaction, emotional closeness, and perceived costs. Univariable and multivariable linear regression analyses were conducted, adjusting for confounding factors. Additionally, positive and negative impacts of dog ownership on mental wellbeing were coded from open questions using thematic analysis. A stronger dog–owner relationship was associated with greater feelings of emotional support and companionship but poorer mental health in terms of anxiety or depression. However, the perceived costs subscale was consistently associated with better mental health outcomes. Direction of causality cannot be inferred as people with poor mental health may acquire dogs to help relieve symptoms, which qualitative analysis supported. Key themes included positive impacts on owner wellbeing and happiness through providing purpose, companionship and self-acceptance, pleasure and distraction, as well as lessening emotional pain and suffering and reducing risk behaviors. However, negative impacts of a strong relationship include anticipatory grief over loss of the dog, and concerns regarding the burden of responsibility and ability to meet dog’s needs. Perceived ability to adequately meet dog’s needs promoted personal growth and positive relationships with others, whereas perceived inability led to feelings of guilt, or anger/frustration, and reduced autonomy and sense of environmental mastery. Dog ownership contributes to both hedonic and eudaimonic wellbeing in multiple ways, including supporting owners through periods of poor mental health and providing purpose. However, the burden of responsibility and owner and dog characteristics can create challenges, and owners may benefit from support in caring for their dogs and reducing problematic behaviors. (shrink)