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When people with mental illness do go to court for committing minor offenses and disorder, the experience is often unsatisfactory, because most prosecutors and judges lack the experience and expertise to handle such cases effectively, including knowledge about mental illness and awareness of treatment options. Also, general criminal court can be chaotic, causing lots of cases to receive only superficial attention. Conversely, in other cases, people with mental illness get unsupervised probation without treatment conditions, compounding deinstitutionalization effects. One remedy for this dilemma is a specialized mental health court, in which one or a few judges hear all such cases and have ready access to mental health professionals. An effort should be made to identify repeat crime victims associated with people with mental illness, because previous victimization is generally the best predictor of future victimization. For example, if Responses to the Problem of People wth Mental Illness 31 a person with mental illness is a repeat victim, an abusive caregiver might be uncovered. Alternatively, it might be discovered that the person frequents risky places or engages in risky behaviors. It is also possible, of course, that the crimes reported by the person with mental illness are imaginary and never happened. Identifying any of these "causes" could lead to solutions that reduce or even eliminate future victimizations. Alternatively, people with mental illness might habitually victimize others-caregivers, family members, employers. From the standpoints of equity and prevention, it is important to provide information and services to people with mental illness who are crime victims, as well as to people who are victimized by people with mental illness. It should be noted that a person with mental illness who is a crime victim may experience more trauma than another person, including the possibility that memories of past abuses can be triggered. Similarly, family members of a person with mental illness who are victimized by that person may experience extra fear, anger, remorse, or even guilt because of the intimate relationships involved. When the situation was finally targeted, it was determined that the real victim was a mother who lived in the house with her grown daughter. The daughter, who suffered from mental illness, abused and intimidated her mother. Justice Department Office for Victims of Crime, and the National Alliance for the Mentally Ill, among others. It is widely recognized that a relatively small proportion of offenders commit a relatively large proportion of offenses. If people with mental illness are identified who are repeat criminal offenders, attention should be focused on them. This may involve criminal charges, involuntary commitment, better guardianship, court-ordered medication, restraining orders, or any number of other techniques, depending on the circumstances. The key is to focus attention on anyone who is responsible for a disproportionate share of a problem. Similarly, there may be community members who commit repeat crimes against people with mental illness. The perpetrators might be caregivers, family members, neighbors, or relative strangers. Because people with mental illness who report crimes are sometimes treated with skepticism and suspicion, those who repeatedly victimize them may be more difficult to identify than should be the case. Chronic disturbances involving people with mental illness are among the most frustrating situations for police, because there are few options available to officers. If a person with mental illness is merely being loud, being annoying, or acting strangely, involuntary civil commitment is not usually an option, because the person is not putting himself or others in danger. In response to any particular incident, officers might attempt informal "soothing or smoothing,"56 look for a guardian, command the individual to cease or leave, or make an arrest for disorderly conduct. When the same person engages in the same behavior repeatedly, however, officers may run out of options quickly, especially if the jail tightens its criteria on accepting people with mental illness. The situation is exacerbated if there are complainants who expect the officer to do something. Although easy solutions may not be available, it is nevertheless productive to target those people responsible for repeat or chronic disturbances. In San Diego, for example, police received an average of four calls per month about a man who was disruptive and threatening in his neighborhood. When police targeted him, they were able to meet with him, gather his history, and then use criminal charges and probation conditions to exercise greater control over him.

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The ill person will need treatment that addresses the substance use and mental health problems at the same time. Services are available at camh to help families cope with the added burden of a substance use problem and 10 Promoting Recovery its impact on the whole family. A family member writes: From our experience, we are aware that both drug and mental rehabilitation are precarious, unpredictable processes. Taking a "tough love" approach in dealing with our son was one of the hardest decisions we have ever had to make in our lives. We refused to take our son home until he was willing to enrol in a drug rehabilitation program. At the time, he switched from shelter to shelter and occasionally slept on the street. He agreed to take his antipsychotic medication every day, continue to remain sober by attending his drug rehabilitation program and participate in the ged [Graduate Equivalency Diploma] program. His determination to "get back on track" was strong and we were committed to help him in his recovery as much as we could. As parents, we need the strength to handle the misfortune of having two sons succumb to the lure of the drug culture and to have both suffer from mental illness. Psychosocial rehabilitation refers to non-biological interventions that focus on other determinants of mental health. The type of services clients access-and when they choose to access them-will depend largely on what they are looking for and where they are in the stages of recovery. Services in the outpatient programs include counselling, life skills training, assistance with returning to school or work, recreation and social planning, and assistance with accessing government services and community resources. Education and support for families is also a vital part of psychosocial rehabilitation. Psychosocial services are available to all clients of the fed, both inpatient and outpatient, as well as their families. Although these supports are available and helpful, there is often a conflict between family members who want their relative to use these services and their relative who may not be ready to join them. In addition to this, the case manager co-ordinates with the rest of the treatment team. Supportive counselling is focused on the present rather than issues pertaining to early childhood events or complicated psychological 12 Promoting Recovery issues. The focus of the work is on helping the person cope with the illness and set short-term goals. Art, pet and music therapy are also available to allow creative expression, which is important for recovery. Many young people with a psychotic illness need assistance in developing life and social skills. Young people who have difficulty engaging with other people or who have been isolated for a long time may need social skills training and opportunities for social interaction. Others who are learning to live on their own may find that life skills training. Your relative may need support from the treatment team and the family to decide when to return to class and to determine appropriate course loads and what kinds of additional supports and accommodations are needed. High schools, colleges and universities often require collaboration with the treatment team. Assistance will also be provided by the inpatient social worker or case manager to locate alternative schools, enrol your relative in a college or university and connect with other educational services. One of the most difficult aspects for families with this illness is having to consider modifying their expectations for the future potential of their relative. Work closely with your relative and the treatment team to set up realistic goals and expectations. Young people are often in the process of finding a career when the illness strikes. For a person with a psychotic illness, 13 Promoting Recovery from First Episode Psychosis this rite of passage can be seriously disrupted.

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There are days when I feel terrible while running, when pain and fatigue seem overpowering. Running has changed my life physically-not only a healthier cardiovascular system, but losing twenty-five pounds, going from size 14 to size 3; socially meeting many new people on the road, at races and in the running club to which I belong; intellectually-producing greater creativity and concentration; spiritually-providing quiet solitude in which to pray and meditate on things of God; and emotionally-creating more patience, stability, strength, confidence, and a sense of self-worth. This all-male family occurs naturally in high histamine women since their vaginal secretions are more dilute, and the male sperm wins in the race to fertilize the ovum. Her hair analysis showed low manganese, magnesium, and chromium, but she was not hypoglycemic by the blood spermine test. She had severe insomnia partially induced by the 30 mgm per day of Deseryl needed to temper her depression. On the standard treatment program for histadelia, she is now much better and, furthermore, she understands the biochemical nature of her illness. Two such peptides, substance P and cholecystokinin and its derivatives have been studied due to their effects on dopaminergic pathways as possibly related to schizophrenic symptoms. The "dopamine hypothesis" attributes the psychiatric symptomatology of the schizophrenics to an impaired regulation of the neurotransmitter dopamine. Dopamine is concentrated within the basal ganglia and limbic system of the brain, thus centrally acting with other neurohumors to coordinate body movement, memory, emotions, and learning. An overreactive dopaminergic system has been implicated in schizophrenia; however, despite numerous studies, evidence remains intangible. Originally identified as the neurotransmitter involved in the conduction of pain, subsequent studies have delineated a greatly expanded role for substance P in the central nervous system. High concentrations of substance P have been localized in the basal ganglia, hypothalamus, substantia nigra, and the central grey region of the brain. The distribution of substance P is markedly similar to that of dopamine suggesting interactions. Substance P plays a facilitory role in dopaminergic pathways, stimulating release of the dopamine neurotransmitter. Excess production and release of substance P would lead to an overabundance of dopamine resulting perhaps in schizophrenic difficulties. Cholecystokinin is antagonistic to the release of dopamine from limbic neurons and, thus, may serve as a regulatory system controlling hyperfunctioning dopaminergic neurons. Since the early seventies, numerous studies have concentrated on correlations between monoamine oxidase activity and the schizophrenias. Studies of monozygotic (identical) twins show striking similarities between monoamine oxidase activities in the two offspring. Chronic schizophrenics were shown to have only 41% of the monoamine oxidase activity of normals. The "phenylethylamine theory" states that phenylethylamine produces an amphetamine-like psychosis. Three of five studies have documented increased urinary excretion of phenylethylamine in diagnosed schizophrenics. However, chronic paranoids were not differentiated from the general schizophrenic population. An unusually high concentration of norepinephrine was localized in the ventral, septum, stria terminalis, nucleus accumbens, and mammillary bodies. This may explain why paranoid schizophrenics slowly improve with age without any effective treatment. Certainly, the aforementioned factors may cause an imbalance in monoamine oxidase levels and production; whether they alone may precipitate a psychotic episode remains unknown. Testing for monoamine oxidase levels previously involved the assaying of platelets found in the blood. The process is rather involved and, thus, its usefulness as a clinical test is questionable. As previously discussed, others have also found elevated excretion of phenylethylamine.

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Deficiency of iron store, failure to utilize iron properly, and defective heme or porphyrin synthesis are characteristic of iron deficiency anemia, anemia of chronic disease, and the sideroblastic anemias, respectively. In thalassemia syndromes, globin production is decreased, thereby hindering hemoglobin synthesis and producing a microcytic anemia. Iron is incorporated form plasma transferrin into developing erythroblasts in the bone marrow and into reticulocytes. Only a small proportion of plasma iron comes from dietary iron absorbed through the duodenum and jejunum. Iron is also present in muscle as myoglobin and in most cells of the body in ironcontaining enzymes. This tissue iron is less likely to become depleted than hemosiderin, ferritin and hemoglobin in states of iron deficiency, but some reduction of heme-containing enzyme may occur in severe chronic iron deficiency. The proportion can be increased to 20-30% in iron deficiency or pregnancy but, even in these situations, most dietary iron remains unabsorbed. Iron absorption this occurs through the duodenum and less through the jejunum; it is favored by factors such as acid and reducing agents keeping the iron soluble, particularly maintaining it in the ferrous rather than ferric state. In iron deficiency, more iron enters the cell and a greater proportion of this intramucosal iron is transported into portal blood; in iron overload, less iron enters the cell and a greater proportion of this is shed back into the gut lumen. Iron transport Most internal iron exchange is concerned with providing iron to the marrow for erythropoiesis. Iron requirements the amount of iron required each day to compensate for losses from the body and growth varies with age and sex; it is highest in pregnancy and in adolescent and menstruating females. Causes Chronic blood loss, especially uterine or from the gastrointestinal tract is the dominant cause. Half a liter of whole blood contains approximately 250mg of iron and, despite the increased absorption of food iron at an early stage of iron deficiency, negative iron balance is usually in chronic blood loss. These are abnormal erythroblasts containing numerous iron granules arranged in a ring or collar around the nucleus instead of the few randomly distributed iron granules seen when normal erythroblasts are stained for iron. The anemia may be hypochromic or predominantly hemolytic, and the bone marrow may show ring sideroblasts. Clinically they are divided into hydrops fetalis, thalassemia major, which is transfusion dependent, thalassemia intermedia characterized by moderate anemia usually with splenomegaly and iron overload, and thalassemia minor, the usually symptomless carrier. As there is duplication of the -globin gene, deletion of four genes is needed to completely suppress chain synthesis. Since the chain is essential in fetal as well as in adult hemoglobin, deletion of both genes on both chromosomes leads to failure of fetal hemoglobin synthesis with death in utero (hydrops fetalis). Hemoglobin electrophoresis is normal but occasionally Hb H bodies may be observed in reticulocyte preparations. Many target cells are also the hypocrhomia is a result of decreased 254 Hematology cellular content of hemoglobin, a major defect in thalassemia. Several forms of macrocytosis are not accompanied by megaloblastic changes and some of these are relatively common. Anemia associated with hypothyroidism can have various morphologic characteristics, but is sometimes macrocytic in nature, for reasons that are not entirely clear. The postsplenectomy state is often associated with mild macrocytosis, in addition to the formation of some target cells and acanthocytes; these changes are due to the fact that young red cells normally undergo a process of surface remodeling, with loss of some of their redundant red cell membrane, with the spleen, and thus splenectomy may be associated with cells containing excessive plasma membrane material. In these situations there is also a high titer of erythropoietin in the plasma, and this causes a rapid rate of ingress of young red blood cells into the peripheral blood. Major causes of macrocytic anemia that are megaloblastic in nature are vitamin B12 or folic acid deficiency, both of which have multiple causes. It is possible that premature cell death results form this unbalanced cell maturation. Although most anemias characterized by megaloblastic erythropoiesis are due to either vitamin B12 or folic acid deficiency, there are several other causes of megaloblastic hematopoiesis. It has been suggested that these abnormalities result from 261 Hematology fragmentation of the abnormal large red cells as they pass through small arterioles. As the megaloblastic anemia becomes more sever, bizarre shapes such as triangles and helmets increases proportionately. Cells size and average number of lobes in the mature granulocyte (poly) are increased.

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In this frantick Condition they were confined, lest they should in their Folly destroy themselves; though it was observed, that all their Actions were full of Innocence and good Nature. Certainly in our society of a federally regulated pharmaceutical industry, a schizophrenia-like disorder in response to a legally obtained drug is more the exception than the rule. Drugs are rigorously tested before being released in the marketplace, and a propensity for psychotic reactions would lead to certain rejection by the F. One, however, cannot abandon the possibility of a drugrelated disturbance, especially when the course of an acute psychotic illness follows the implementation of a pharmaceutical. Due to inherent differences in the patient population, one patient may be therapeutically aided for years without adverse side effects, while seemingly minor factors may predispose another to mental disaster. A list of drugs with documented cases of schizophrenia-like complications appears below. Since new reports are constantly surfacing, we do not guarantee the completeness of this list, but hope it will provide a general overview of the potential for drug-induced psychoses. Atropine Psychosis Drug or Pharmaceutical Amitriptyline (Elavil, others) Atropine, Belladonna alkaloids Benztropine (Cogentin), Cyclopentolate (Cyclogyl) Cyclopentolate (Cyclogyl) Desipramine (Pertofrane), Desipramine (Pertofrane), Doxepin (Adapin, Sinequan), Doxepin (Adapin, Sinequan), Imipramine (Tofranil, others), Imipramine (Tofranil, others), Nortriptyline (Aventyl), Nortriptyline (Vivactil), Protriptyline (Aventyl), Protriptyline (Vivactil), Scopolamine (Hyosine), Scopolamine (Hyosine), Tricyclic antidepressants, Tricyclic antidepressants, Trimipramine (Surmontil) Trimipramine (Surmontil) 206 Common Symptoms Confusion; memory loss; disorientation; depersonalization; delirium often with delirium often with high fever; auditory, high fever; auditory, visual and tactile visual and tactile hallucinations; fear; hallucinations; fear; paranoia; incoherent paranoia; incoherent speech; flushed, dry speech; flushed, dry skin. The inter-relationship between vitamin B12 and folic acid is such that a deficiency in either of the components will result in the appearance of the full deficiency syndrome. B12 is required for the utilization of the folates, especially in blood formation. Striking rapidly, often without warning, the deficiency attacks the adult eroding both the spiritual and financial foundation of family. The symptoms of B12/folic acid deficiency include all of the classic symptoms of schizophrenia, as well as some unique ramifications on the peripheral nervous system and blood formation. Perhaps the best diagnostic feature, although not always present, is a pernicious or macrocytic anemia unresponsive to iron treatment. Nervous involvements may include encephalopathy, cerebellar atrophy or dysfunction, myelopathy, and peripheral neuropathy. Behavioral manifestations of nervous dysfunctions include headaches, sleeplessness, forgetfulness, irritability, depression, and paranoia. Bachevalier and Botez (1978) have documented severe learning impairments in rats suffering from folic acid deficiency. Kariks and Perry (1970) report B12/folic acid deficiency, with or without a resultant anemia, to be associated with skin diseases, recurrent abortions, celiac disease, gout, tropical sprue, liver disease, rheumatoid arthritis, tuberculosis as well as mental illness, and organic brain disease. In 1954, Bodenoch was the first to draw attention to anti-convulsant drugs used in the treatment of epilepsy and a subsequent folic acid deficiency. Prolonged treatment with phenytoin derivatives may in some epileptics lead to a macrocytic anemia and paranoid psychosis. Kane and Lipton, in an early review, point to five clinical problem areas where altered folate metabolism has been found. In addition to the metabolic and psychiatric complications previously mentioned, the population at risk include mentally retarded children, pregnant and postpartum women, and women taking oral contraceptives. Stone and his colleagues found twenty-two percent of the pregnant women surveyed to be folate deficient. In a report with more profound implications, Read and his coworkers reported eighty percent of the admissions to an old age home to be folate deficient, possibly explaining the symptoms of apathy, withdrawal, and depression common in geriatric patients. More than likely these folate deficiencies in the elderly can be attributed to nutritional deficits and malabsorption syndromes. The data suggests routine monitoring of folic acid and vitamin B12 status for selective patient groups. However, the group which would appear to benefit the greatest from an awareness of B12/folic acid balances is the geriatric community. The implementation of a comprehensive survey and supplementation program may increase longevity, productivity, and the overall quality of life. The patient assumed that the more she would drink the more informative the test would be. Any delay in starting the appropriate treatment may cause irreversible brain damage and, occasionally, death. Because water at no cost can produce altered mental states, one might say cynically, why pay good money for street drugs? Excessive drinking of water (polydipsia) and excessive volumes with urination (polyuria) are common among schizophrenic patients and combine with severe hyposthenuria (which refers to a urine specific gravity of 1.

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True/False: There is a standard for after hours accessibility that all pediatricians adhere to. True/False: There is variability in the use of pediatric subspecialty care that results from factors other than availability of specialists. If a pediatric subspecialist is not available, the pediatrician has the following choices: a. Send the patient to a pediatric subspecialist regardless of cost and inconvenience. Pediatricians may be concerned about giving after hours telephone advice to parents who call. At what age does the uterine environment play a role in the growth of a child versus the influence on growth by the genetic makeup? What is the approximate weight gain in grams per day for a healthy term infant from birth to 3 months of age? How do the growth curves for congenital pathologic short stature, constitutional growth delay, and familial short stature look like? Developmental and behavioral conditions occur in approximately what percentage of children? What is the best clinical situation to try to identify children with developmental disorders from developmentally normal children? Which of these following methods of identifying children with developmental or behavioral concerns has the worst sensitivity? Which of the following have been proven problems regarding the standardized parent developmental screening tools? An assumption that the screening test done at one point in time will discover all children with every type of developmental problem. When is the best age (out of the following suggestions) for a physician to administer a developmental screening tool? Which of the following vaccines would be contraindicated in a 4 year old boy receiving immunosuppressive therapy for autoimmune hepatitis? Which vaccine should not be given to an 8 year old girl who has not been immunized previously? Which parenteral vaccine should not be characterized as an attenuated live virus vaccine? Which passive or active immunization is specifically recommended for women in the second or third trimester of pregnancy? Increased risk for intussusception was observed as a rare complication following immunization with which vaccine? True/False: In infants younger than 6 months of age, early intervention for hearing impaired infants is believed to improve the development of speech, language, and cognition, which in turn, decreases the need for special education. What is the best test for assessing hearing deficits in infants older than 6 months of age? After failing an objective hearing screen, tympanometry testing is conducted and the results are abnormal. True/False: For most problems caused by parental child rearing knowledge deficits, there is good evidence from high quality studies that physicians can change parental behavior through simple counseling in the primary care setting 2. True/False: the anticipatory guidance issues for two year olds are very different for boys as compared to girls. Do to the child what the child does to others so they learn why not to do certain things. True/False: Children can develop fluorosis by using fluoride toothpaste and fluoride supplements. True/False: Parents do not need to supervise their two year olds who have already completed swimming lessons. Children can be offered a variety of nutritious foods and be allowed to choose what to eat and how much. It is abnormal for children at this age to eat a lot for one meal, and not much the next. Toddlers and preschoolers often lack the self-control necessary to express anger and other unpleasant emotions peacefully. This method should be considered with certain types of behaviors including impulsive, aggressive, hostile and emotional behaviors. A good rule of thumb is to use five minutes of time out per year of age (for example 25 minutes for a five year old).

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Such disorders are classified as nutritional, functional, reactive or fed hypoglycemia, because symptoms develop in response to food intake. Alimentary hypoglycemia, one type of nutritional glycemia, often develops in patients who undergo subtotal gastrectomy for peptic ulcers, as foods pass more rapidly into the small intestine when part of the stomach has been removed. Most often, however, prolonged stress, particularly the internal disturbance provoked by poor eating habits, precipitates hypoglycemia. When a person suffers continual stress, the adrenal gland must constantly supply adrenalin. When challenged, it can no longer produce enough adrenalin and hypoglycemia results. Sucrose, the refined sugar in baked goods, sweets and the sugar bowl, consists of a molecule of glucose and a molecule of fructose. When sugar is eaten, enzymes in the small intestine readily break the bond between the two simple sugars and glucose with fructose surges into the blood stream, signalizing the pancreas to release battalions of insulin molecules. Insulin rapidly admits glucose to the cells and the level of glucose in the blood quickly decreases. This action is responsible for the quick, but temporary, energy provided by a bar of candy. Empty Calories Stress the Pancrease and Adrenal Glands When repeatedly forced to handle large amounts of glucose (derived from a diet rich in refined sugars), the pancreas becomes sensitized and hypoglycemia develops. Every time glucose enters the blood, the pancreas overreacts, releasing too much insulin which causes the cells to absorb and utilize glucose at top speed. The adrenal gland, striving to maintain the proper glucose level, becomes exhausted. Another dose of sugar relieves symptoms for a short time, so many hypoglycemics snack continually on sweets, without minerals, a pattern which only aggravates the underlying metabolic disorder. Too Much Sugar Increased consumption of refined carbohydrates during the past 50 years probably accounts for the rising incidence of diabetes and hypoglycemia in recent times. In the 19th century, the per capita intake of sugar in England was only seven pounds per person a year. Today, people in the western countries consume as much as 128 pounds of sugar per year, and the human body cannot adapt to this drastic change. Mark Twain once advised that the "secret to success in life is to eat what you like and let the food fight it out inside," but this statement came sometime before the present avalanche of sugary foods reached the market. Today, most people eat to satisfy their sweet tooth with refined carbohydrates and the food is indeed "fighting it out inside," and in many cases wholly defeating the glucose regulatory mechanisms. Doctors specializing in metabolic disorders estimate that at least one in twenty people suffer from hypoglycemia. But since sugar is cheap, mildly addictive (and there are many sugar addicts about) and extends the shelf life of many foods, it is little wonder that the food industry puts 30% sugar into ketchup and 23% into sauces and salad dressings. When cells utilize available glucose so rapidly that the blood cannot readily meet the constant demand for more fuel, the cells actually become starved. Glucose deficiency drastically alters the function of the brain, since the brain cells cannot store glucose and, thus, require a continuous supply to generate energy. In a state of glucose starvation, the brain suffers reduced efficiency and can no longer completely direct vital processes, thus disrupting physical and emotional behavior. Physical and emotional disturbances in the hypoglycemic disorders vary according to the severity of the disorder and the individual affected. Mental symptoms frequently resulting from hypoglycemia include fatigue, irritability, nervousness, insomnia, mental confusion or forgetfulness, inability to concentrate, anxiety, phobias and fears, disperceptions, disruptive outbursts, and headaches. Such symptoms are non-specific and present in many disorders, but strongly indicate hypoglycemia when they occur from time to time, after fasting, late at night, first thing in the morning, or in direct relation to the time or content of a meal. Low Blood Pressure and Low Body Temperature Is a Clue A distinctive characteristic of hypoglycemia is low blood pressure and lowered body temperature. Hypoglycemics often complain of cold hands and feet and many experience cold sweats. Both doctors attribute this phenomenon to the effect of glucose deficiency on brain cells, since the hypothalamus controls body temperature. Manganese raises blood pressure and all hypoglycemic patients are deficient in manganese. Hypoglycemia is Easy to Treat For many "diseases of lifestyle" the outlook is grim but not so for hypoglycemia. These patients, either nearing completion of a pregnancy or having just given birth, experience disturbances as a result of their rapidly changing biochemical state.

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This could be reassurance, a period of observation, performing investigations or therapeutic intervention. Pattern of child development Cognitive development 31 31 32 33 34 34 Analysing developmental progress Developmental screening and assessment Child health surveillance Hearing Vision 34 41 42 42 44 3 Children acquire functional skills throughout child hood. During school age, evidence of developmentalprogressionispredominantlythrough cognitivedevelopmentandabstractthinking,although thereisalsosomefurthermaturationofearlydevelop mentalskills. Normaldevelopmentinthefirstfewyearsoflifeis monitored: this chapter covers normal development. Delayed or abnormal development and the child with special needsareconsideredinChapter4. Heredity determines the potential of the child, while the environment influences the extent to which that potential is achieved. Vision and fine motor Gross motor Developmental milestones Hearing, speech and language Social, emotional and behavioural Figure 3. Justasthereare normal ranges for changes in body size with age, so there are ranges over which new skills are acquired. Asfinemotorskillsrequire good vision, these are grouped together; similarly, normal speech and language development depends onreasonablehearingandsothesearealsoconsidered together. Theacquisitionofdevelopmentalabilitiesforeach skill field follows a remarkably constant pattern between children, but may vary in rate. Median and limit ages Thedifferencebetweenmedianandlimitagesisshown by considering the age range for the developmental milestoneofwalkingunsupported. Of those not achieving the limit age, many will be normal late walkers, but a proportion will have an underlyingproblem,suchascerebralpalsy,aprimary muscledisorderorglobaldevelopmentaldelay. For example, of children who become mobile by bottomshuffling, 50% will walk independ ently by 18 months and 97. Variation in the pattern of development There is variation in the pattern of development between children. Taking motor development as an example, normal motor development is the progres sionfromimmobilitytowalking,butnotallchildrendo so in the same way. While most achieve mobility by crawling(83%),somebottomshuffleandotherscrawl withtheirabdomenonthefloor,socalledcommando crawling(creeping)(Fig. The locomotor pattern (crawling, creeping, shuffling, just standing up) determines the age of sitting,standingandwalking. Childrenwhobottomshuffleor commando crawl tend to walk later than crawlers, so thatwithinthosenotwalkingat18monthstherewill be some children who demonstrate a locomotor variantpattern,withtheirdevelopmentalprogressstill Is development normal? Normaldevelop mentimpliessteadyprogressinallfourdevelopmental fields with acquisition of skills occurring before limit agesarereached. As children grow older and acquire furtherskills,itbecomeseasiertomakeamoreaccu rate assessment of their abilities and developmental status. Analysing developmental progress Detailed assessment So far, emphasis has been mainly on thinking about developmental progress in a longitudinal way, taking eachskillfieldanditsprogressionseparately,andthen relating the progress in each to the others and to chronologicalage. Thisisthefundamentalconceptof learning how to think about developmental assess ment of children. Detailed questioning and observa tionisrequiredtoassesschildrenwithdevelopmental problemsbutisunnecessarywhenscreeningdevelop mental progress in normal clinical practice, when a shortcutapproachcanbeadopted. In middleschool children, the dominant mode of thoughtispracticalandorderly,tiedtoimmediatecir cumstances and specific experiences. The age at which developmental progressacceleratesdiffersineachofthedevelopmen talfields. It directs the assessment to current abilities instead of concentrating on parents trying toremembertheagewhentheirchildacquireddevel opmentalmilestonessometimeinthepast.


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