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During the initial Assessment process, much time is spent getting to know each individual and their team members. Information about the individual, their interests, preferences, medical needs, etc. Services are explained, questions answered, and the wishes and expectations of the entire team are discussed. Planning, which includes looking at future dreams, goals and desires, is discussed. Participation in community building activities establish a link between recreational, and leisure activities and the development of a community support network. Evaluating and Improving the Quality of Services: Feedback from participants, employers, families, and agencies is used to determine satisfaction with the services and outcomes. Staff performance evaluations include feedback from individuals, employers, parents, and other agencies. Training and Evaluating Staff: An extensive 4-week initial training includes individualized sessions with the Director and Assistant Director utilizing a manual, videos and discussions. New employees are trained by team members until they are experienced enough to be independent. The primary factor in calculating cost of service is the number of direct staff hours consumed by the individual plan. The individual rate is based on the number of direct hours of support required per week to pursue the individual choices in the Individual Support Plan, regardless of the funding source. Also included in the rate is indirect support required for travel time to meetings, advocacy and case management. This is accomplished through team collaboration, strong relationship building, advocacy, individual assessments and service plans, continuing education and training, community involvement, and a commitment to quality. Staff providing medically based services receive direct training and oversight from a contracted nursing agency. Medically based services include skin integrity maintenance protocols, enteral (G-tube) nutrition administration, seizure monitoring/tracking, medication administration, and intense personal care. Our facility utilizes various types of adaptive and assistive equipment to ensure client and staff safety. Staff providing social and skill development services create unique individual and group activities that encourage active and passive participation. Involving Client and Guardian in Developing Supports and Services: Services and goals for participants are developed with the assistance of a team. Team members follow the lead of the participant or guardian to develop, maintain, and modify services and goals. Emergency plans are created, trained, and rehearsed as required and/or needed to maintain safety. Client service teams create, review, and adapt individual services plans to maintain safety. Evaluating and Improving the Quality of Services: Feedback from participants, families, and agencies is used to determine satisfaction with the services and outcomes. Additional training topics include medication administration and management, mealtime issues (swallowing difficulty), dementia specialist, adaptive ambulation techniques, understanding seizure activity, community protection, skin integrity techniques, facility and equipment sanitation, etc. Staff training needs are constantly evaluated and modified to ensure a high standard for training and safety. Training efforts are met during regular business hours during participant attendance as well as five annual in-service days. Service costs are determined by calculating the number of staff hours required to provide services. Please contact the Program Director to schedule a time for a tour or to get more information. The intensive personal care and health maintenance needs usually dominate the program. Services Provided: Supported Employment; vocational counseling; vocational assessments; job-seeking skills; recreation and daily living skills.

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The official recommendation of the World Health Organization is a single dose administered during infancy. Some studies show bacille Calmette-Guйrin to provide 80% to 90% protection from tuberculosis, and other studies show no protective efficacy at all. When a reaction does occur, the induration size is usually less than 10 mm, and the reaction wanes after several years. Interaction with these molecules facilitates membrane fusion and cell entry by the virus. Because helper T cells are important for delayed hypersensitivity, T cell­dependent B cell antibody production, and T cell­mediated lymphokine activation of macrophages, their destruction produces a profound combined (B and T cell) immunodeficiency. A lack of T cell regulation and unrestrained antigenic stimulation result in polyclonal hypergammaglobulinemia with nonspecific and ineffective globulins. Transmission by contaminated blood and blood products has been eliminated in developed countries but still occurs in developing countries. Most pediatric cases now occur in adolescents who engage in unprotected sexual activities. Initial symptoms with vertical transmission vary and may include failure to thrive, neurodevelopmental delay, lymphadenopathy, hepatosplenomegaly, chronic or recurrent diarrhea, interstitial pneumonia, or oral thrush. Prominence of individual symptoms, such as diarrhea, may suggest other etiologies. Maternal antibodies may be detectable until 12 to 15 months of age, and a positive serologic test is not considered diagnostic until 18 months of age. Diagnostic viral testing should be performed by 48 hours of age, at 1 to 2 months of age, and at 3 to 6 months of age. An additional test at 14 days of age is often performed because the diagnostic sensitivity increases rapidly by 2 weeks of age. Initiation of antiretroviral therapy while the patient is still asymptomatic may preserve immune function and prevent clinical progression but incurs the adverse effects of therapy and may facilitate emergence of drug-resistant virus. Examples of conditions in clinical category B include, but are not limited to, the following: Anemia (<8 g/dL), neutropenia (<1000/mm3), or thrombocytopenia (<100,000/mm3) persisting 30 days Bacterial meningitis, pneumonia, or sepsis (single episode) Candidiasis, oropharyngeal. Routine immunizations are recommended to prevent vaccine-preventable infections but may result in suboptimal immune responses. Effective combination therapy significantly reduces viral loads and leads to the amelioration of clinical symptoms and opportunistic infections. Oral and gastrointestinal candidiasis is common in children and usually responds to imidazole therapy. Risk of death is directly related to the degree of immunosuppression, viral load, and young age. Adult prevention results from behavior changes such as safe-sex practices, decrease in intravenous drug use, and needle exchange programs. The rate of vertical transmission is reduced to less than 8% by chemoprophylaxis with a regimen of zidovudine to the mother (100 mg five times/24 hours orally) started by 4 weeks gestation, continued during delivery (2 mg/kg loading dose intravenously followed by 1 mg/kg/hour intravenously), and then administered to the newborn for the first 6 weeks of life (2 mg/kg every 6 hours orally). Other regimens incorporating single-dose nevirapine for infants have been shown to be similarly effective and are used in developing countries. The current recommendations for the United States include a 6-week prophylactic with zidovudine for the infant in combination with maternal intrapartum therapy. Characterization of signs and symptoms should identify factors such as triggers; actions that alleviate the symptom; timing, frequency and duration of symptoms; relationship to meals and defecation; and associated symptoms. Other key history includes exposures to others (family, school contacts), travel, environmental exposure, and impact of illness on the child (school absences). Tests of liver dysfunction include total and direct bilirubin, alanine aminotransferase, aspartate aminotransferase for evidence of hepatocellular injury, and -glutamyltransferase or alkaline phosphatase for evidence of bile duct injury. Hepatic synthetic function can be assessed by coagulation factor levels, prothrombin time, and albumin level. Pancreatic enzyme tests (amylase, lipase) provide evidence of pancreatic injury or inflammation. The examination should begin with a careful external inspection for abdominal distention, bruising or discoloration, abnormal veins, jaundice, surgical scars, and ostomies.

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Only 12% of children 12 and under with poisoning require treatment in a health care facility, compared with 48% of adolescents. Clear goals should be identified to allow provision of optimal analgesia or sedation without compromising the physiologic status of the patient. Anxiolysis, cooperation, amnesia, immobility, and lack of awareness all are goals of sedation and can be accomplished with various drugs (Table 46-1). Many of these goals can be achieved with behavioral techniques (preprocedural teaching), but sedation is often a necessary adjunct for painful procedures. Pain may be expressed by verbal or visible discomfort, crying, agitation, tachycardia, hypertension, and tachypnea. A variety of scales have been developed in an attempt to quantify pain and allow more directed therapy. Few of these scales are well validated, especially in populations of acutely ill children with physiologic derangements secondary to the underlying pathology. Pain caused by procedural interventions should always be treated with analgesics in addition to sedation (Table 46-2). Specific attention must be paid to assessment of the airway (for ability to maintain a patent airway) and respiratory system (asthma, recent respiratory illness, loose teeth), cardiovascular status (especially adequacy of volume status), factors affecting drug metabolism (renal or liver disease), and risk of aspiration (adequate nothing-by-mouth status, gastroesophageal reflux). During the administration of procedural sedation, assessment of status must include monitoring of oxygen saturation, heart rate, and respiratory rate, as well as some assessment of effectiveness of ventilation. This assessment must be performed by someone who is not involved in the procedure; this person is also responsible for recording vital signs and drugs administered on a time-based graph. The most common choice is a combination of a longer acting benzodiazepine and an opioid. Use of appropriate pain and sedation scores allows for titration of medications to achieve goals of the sedation plan. Long-term use of benzodiazepines and opioids leads to tolerance, a problematic occurrence that must be considered as medications are added and weaned. True addiction is a rare occurrence, especially when medications are provided at the minimum level needed to achieve adequate sedation and pain control. Visual analog scales, developed for adult patients (allowing patients to rate pain on a scale of 1 to 10), have been used for older children. Pain scales for younger children often incorporate behavioral and physiologic parameters, despite the imprecision of physiologic responses. Patient-controlled analgesia is an effective method for providing balanced analgesia care in older children and adolescents. Children using patient-controlled analgesia have better pain relief and experience less sedation than patients receiving intermittent, nurse-controlled, bolus analgesics. Analgesics can be administered through the patient-controlled analgesia pump with continuous basal infusions, bolus administration, or both. Epidural analgesia decreases the need for inhalation anesthetics during surgery and can provide significant analgesia without sedation in the postoperative period. Decreased costs and length of stay also may be benefits of epidural analgesic approaches. Adverse effects include nausea and vomiting, motor blockade, and technical problems requiring catheter removal. At 1 year of age, the number approaches 7%, because some anomalies may not be identifiable until after the neonatal period. The prevalence of congenital malformations is much greater in inpatient pediatric populations; 30% to 50% of hospitalized children have congenital anomalies or genetic disorders. The purine nucleotides, adenine and guanine, cross-link by hydrogen bonds to the pyrimidines, thymine and cytosine. Human cells have 23 pairs of chromosomes, with one copy of each chromosome inherited from each parent. Twenty-two pairs of chromosomes are autosomes; the remaining pair is called the sex chromosomes. In the open reading frame, every three nucleotides represent a single codon, coding for a particular amino acid. In this way, the sequence of bases dictates the sequence of amino acids in the corresponding protein. Some codons, rather than coding for a specific amino acid, act as a "start" signal, whereas others serve as "stop" signals.

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The effects of methylphenidate on the mother­child interactions of hyperactive children. The speech of hyperactive children and their mothers: Comparisons with normal children and stimulant drug effects. Driving in young adults with attention deficit hyperactivity disorder: Knowledge, performance, adverse outcomes and the role of executive functions. Motor vehicle driving competencies and risks in teens and young adults with attention deficit hyperactivity disorder. Preschool children with high levels of disruptive behavior: Three-year outcomes as a function of adaptive disability. A comparison of objective measures of activity level and distractibility in hyperactive and nonhyperactive children. Performance of the Test of Everyday Attention and standard tests of attention following severe traumatic brain injury. Paper presented at the meeting of the Society for Research in Child and Adolescent Psychopathology, London. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1363­1371. Executive processing and attention deficit hyperactivity disorder: An application of the supervisory attentional system. Hyperactive and normal girls and boys: Mother­child interactions, parent psychiatric status, and child psychopathology. The structure of attention-deficit and hyperactivity symptoms among Native and non-Native elementary school children. Cognitive, behavioral, and emotional problems among school-age children of alcoholic parents. A comprehensive evaluation of attention deficit disorder with and without hyperactivity. Executive functioning, temporal discounting, and sense of time in adolescents with attention deficit hyperactivity disorder and oppositional defiant disorder. Persistence of attention deficit hyperactivity disorder into adulthood as a function of reporting source and definition of disorder. Frontal lobe functions in attention deficit disorder with and without hyperactivity: A review and research report. Driving-related risks and outcomes of attention deficit hyperactivity disorder in adolescents and young adults: A 3­5 year followup survey. Developmental changes in the mother­child interactions of hyperactive boys: Effects of two dose levels of Ritalin. Development and functional significance of private speech among attentiondeficit hyperactivity disorder and normal boys. Evidence of a familial association between attention deficit disorder and major affective disorders. High risk for attention deficit hyperactivity disorder among children of parents with childhood onset of the disorder: A pilot study. Attention-deficit hyperactivity disorder and juvenile mania: An overlooked comorbidity? Parentbased diagnosis of attention deficit disorder predicts a diagnosis based on teacher report. Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Mental health in pediatric settings: Distribution of disorders and factors related to service use. Mothers and fathers interacting in dyads and triads with normal and hyperactive sons.

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Screen Failures Screen failures are defined as participants who consent to participate in the clinical study but are not subsequently randomly assigned to study intervention. Individuals who do not meet the criteria for participation in this study (screen failure) may be rescreened under a different participant number. Criteria for Temporarily Delaying Enrollment/Randomization/Study Intervention Administration the following conditions are temporary or self-limiting and a participant may be vaccinated once the condition(s) has/have resolved and no other exclusion criteria are met. Receipt of any seasonal or pandemic influenza vaccine within 14 days, or any other nonstudy vaccine within 28 days, before study intervention administration. Anticipated receipt of any seasonal or pandemic influenza vaccine within 14 days, or any other nonstudy vaccine within 28 days, after study intervention administration. Study intervention administration should be delayed until systemic corticosteroid use has been discontinued for at least 28 days. Inhaled/nebulized, intra-articular, intrabursal, or topical (skin or eyes) corticosteroids are permitted. Each plastic vial as open-label vial will be labeled as vial will be labeled as supply. Study intervention should be administered intramuscularly into the deltoid muscle, preferably of the nondominant arm, by an unblinded administrator. Standard vaccination practices must be observed and vaccine must not be injected into blood vessels. Appropriate medication and other supportive measures for management of an acute hypersensitivity reaction should be available in accordance with local guidelines for standard immunization practices. The investigator or designee must confirm appropriate temperature conditions have been maintained during transit for all study interventions received and any discrepancies are reported and resolved before use of the study intervention. Only participants enrolled in the study may receive study intervention and only authorized site staff may supply or administer study intervention. All study interventions must be stored in a secure, environmentally controlled, and monitored (manual or automated recording) area in accordance with the labeled storage conditions with access limited to the investigator and authorized site staff. At a minimum, daily minimum and maximum temperatures for all site storage locations must be documented and available upon request. Any excursions from the study intervention label storage conditions should be reported to Pfizer upon discovery along with any actions taken. The site should actively pursue options for returning the study intervention to the storage conditions described in the labeling, as soon as possible. Once an excursion is identified, the study intervention must be quarantined and not used until Pfizer provides permission to use the study intervention. All study interventions will be accounted for using a study intervention accountability form/record. If destruction is authorized to take place at the investigator site, the investigator must ensure that the materials are destroyed in compliance with applicable environmental regulations, institutional policy, and any special instructions provided by Pfizer. The study intervention will be administered in such a way to ensure the participants remain blinded. The site personnel will then be provided with a vaccine assignment and randomization number. Blinding of Site Personnel In this observer blinded study, the study staff receiving, storing, dispensing, preparing, and administering the study interventions will be unblinded. All other study and site personnel, including the investigator, investigator staff, and participants, will be blinded to study intervention assignments. The responsibility of the unblinded dispenser and administrator must be assigned to an individual or individuals who will not participate in the evaluation of any study participants. Contact between the unblinded dispenser and study participants and unblinded administrator and study participants should be kept to a minimum. Blinding of the Sponsor To facilitate rapid review of data in real time, sponsor staff will be unblinded to study intervention allocation for the participants in Phase 1. The majority of sponsor staff will be blinded to study intervention allocation in Phase 2/3. All laboratory testing personnel performing serology assays will remain blinded to study intervention assigned/received throughout the study. The following sponsor staff, who will have no part in the blinded conduct of the study, will be unblinded in Phase 2/3 (further details will be provided in a data blinding plan): · Those study team members who are involved in ensuring that protocol requirements for study intervention preparation, handling, allocation, and administration are fulfilled at the site will be unblinded for the duration of the study (eg, unblinded study manager, unblinded clinical research associate).

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Number of People Currently Served: 40 Areas of Expertise: Dungarvin provides services to individuals with a wide variety of disabilities. We have extensive experience with individuals needing very involved medical as well as behavioral supports. Involving the Client and Guardian in Developing Supports and Services: the process of providing support will begin with a meeting between Dungarvin and the individual/guardian and friends for the purpose of recording their desires and what Dungarvin can do to meet those desires. The individual receiving supports and/or the guardian have input into the hiring process if they choose. When possible, the person purchasing support will decide on the location of their residence. Creating Community Involvement: Community involvement begins with the choice of the individual. If he/she expresses a desire for involvement, then a plan is developed according to their preferences. For example, an individual wanting to be connected to their church would be assisted with introductions, volunteer opportunities, etc. Ensuring Safety: Dungarvin policy and procedure ensures that appropriate safety practices are in place and regular training ensures that the practice is carried out. Dungarvin utilizes the services of a national corporation in this background search. Each home is reviewed on a monthly basis utilizing a checklist which is completed by the program director for that home. Any person involved in the lives of the people Dungarvin supports is encouraged to communicate any safety concerns they may have. Evaluating and Improving the Quality of Services: Dungarvin has a systematic process of ongoing assessment to ensure quality. Each program director responsible for the home is required to ensure that the staff has appropriate training which includes a variety of pre-service and orientation training as well as training specific to the individual. Dungarvin has also set up a quality assurance program both on the state and national level where program assessment teams come into the homes and evaluate quality. Each person also receives training within the home specific to the individuals being served. This training may be one complete shift or many shifts depending on the needs presented. All new employees are subjected to a competency evaluation during their first 90 days. If there is not a history for a particular individual Dungarvin is going to serve, then anticipated costs are developed utilizing data from a similar situation. Other Information: Dungarvin helps people have a full social life and develop friendships by looking at the choices of the individual being served and developing an activity plan based on those choices. Community involvement through volunteering, participating in community activities and getting to know the neighbors is all part of the process. We also take advantage of the many opportunities there are in Madison for reduced cost tickets to a large variety of events. Dungarvin prefers to work with one or two local developers who have proven themselves to be accommodating when helping people find accessible housing. We assist the individual in locating a home or apartment when accessibility is not a concern. The next step is to assist the people we support in leasing the home or apartment. Finding a roommate begins with an initial visit which is typically brief to allow the individuals involved to begin to get to know one another. After the initial visit there is usually additional visits until both people are comfortable that this will be a good match. In some cases we have had people stay overnight a couple of times before deciding. Dungarvin utilizes a 24-hour on-call system which allows for an employee to call a supervisor about any problem and get assistance. We also have an on-call system for our nurses making them available to our program directors as needed.


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When combined with a token economy, peer tutoring has been found to yield dramatic academic gains. During the after-noon, when problem solving skills are especially poor, more active, nonacademic activities should be scheduled. Novelty Presentation of novel, interesting, highly motivating material will improve attention. For example, in-creasing the novelty and interest level of tasks through use of increased stimulation. About Us Structure and organization Lessons should be carefully structured and important points clearly identified. For example, providing a lecture outline is a helpful note-taking aid that increases memory of main ideas. It is also helpful if rules are reviewed before activity transitions and following school breaks. For example, token economy systems are especially effective when the rules for these programs are reviewed daily. For example, use of a tape with tones placed at irregular intervals to remind students to monitor their on-task behavior has been found to improve arithmetic productivity. Further, to ensure understanding, it is helpful if these students are asked to rephrase directions in their own words. Additionally, teachers must be prepared to repeat directions frequently, and recognize that students often may not have paid attention to what was said. Other examples might include a trip to the office, a chance to sharpen a pencil, taking a note to another teacher, watering the plants, feeding classroom pets, or simply standing at a desk while completing classwork. Alternating seat work activities with other activities that allow for movement is essential. It is also important to keep in mind that on some days it will be more difficult for the student to sit still than on others. However, as these students have difficulty paying attention to begin with, it is important that attractive alternatives to the task at hand be minimized. It is important to keep in mind that some situations will be more difficult for than others. Contingency management: Encouraging appropriate behavior Although classroom environment changes can be helpful in reducing problematic behaviors and learn-ing difficulties, by themselves they are typically not sufficient. Thus, contingencies need to be available that reinforce appropriate or desired behaviors, and discourage inappropriate or undesired behaviors. Powerful external reinforcement First, it is important to keep in mind that the contingencies or consequences used with these students must be delivered more immediately and frequently than is typically the case. However, before negative consequences can be implemented, appropriate and rich incentives should first be developed to reinforce desired behavior. It is important to give much encouragement, praise and affection as these students are easily discouraged. When negative consequences are administered, they should be given in a fashion that does not embarrass or put down students. Also, it is important to keep in mind that the rewards used with these students lose their reinforcing power quickly and must be changed or rotated frequently. These tokens are in turn ex-changed for tangible rewards or privileges at specified times. Response-cost programs While verbal reprimands are sufficient for some students, more powerful negative consequences, such as response-cost programs, are needed for others. For example, a student may lose earned points or privileges when previously specified rules are broken. At the end of the period or day, students are typically allowed to exchange the points they have earned for a tangible reward or privilege. Time-out Removing the student from positive reinforcement, or time-out, typically involves removing the student from classroom activities. Time-out can be effective in reducing aggressive and disruptive actions in the classroom, especially when these behaviors are strengthened by peer attention. They are not helpful, however, when problem behavior is a result of the students desire to avoid school work. The time-out area should be a pleasant environment and a student should be placed in it for only a short time.

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Eron, Television and the Aggressive Child: A Cross-National Comparison (Hillsdale, N. Noble, "Social Learning from Everyday Television," in Learning from Television: Psychological and Educational Research, edited by M. One such longitudinal study is Anderson and others, "Early Childhood Television Viewing" (see note 60). Battle, "Home Computers and School Performance," the Information Society 15 (1999): 1­10; L. Jackson and others, "Does Home Internet Use Influence the Academic Performance of Low-Income Children? Anderson, "Attentional Inertia and Recognition Memory in Adult Television Viewing," Communication Research 20 (1993): 777­99. Anderson and others, "Watching Children Watch Television," Attention and Cognitive Development, edited by G. Schmitt, "Infants, Toddlers, and Television: the Ecology of the Home," Zero to Three 22 (2001): 17­23. Comstock and Paik, Television and the American Child (see note 54); Fetler, "Television Viewing and School Achievement" (see note 56). Fisch, Transfer of Learning from Educational Television: Near and Far Transfer from Cyberchase, poster presented at the biennial meeting of the Society for Research in Child Development, Atlanta, Ga. Anderson, "Transfer of Learning in Informal Education: the Case of Television," in Transfer of Learning from a Modern Multidisciplinary Perspective, edited by J. Stein, "Prosocial Television and Young Children: the Effects of Verbal Labeling and Role Playing on Learning and Behavior," Child Development 46 (1975): 27­38; P. Bogatz, Reading with Television: An Evaluation of "The Electric Company" (Princeton, N. Boller and others, Using Television as a Teaching Tool: the Impacts of Ready to Learn Workshops on Parents, Educators, and the Children in Their Care (Princeton, N. Vandewater Summary Marie Evans Schmidt and Elizabeth Vandewater review research on links between various types of electronic media and the cognitive skills of school-aged children and adolescents. One central finding of studies to date, they say, is that the content delivered by electronic media is far more influential than the media themselves. When it comes to particular cognitive skills, say the authors, researchers have found that electronic media, particularly video games, can enhance visual spatial skills, such as visual tracking, mental rotation, and target localization. Researchers have yet to understand fully the issue of transfer of learning from electronic media. Studies suggest that, under some circumstances, young people are able to transfer what they learn from electronic media to other applications, but analysts are uncertain how such transfer occurs. In response to growing public concern about possible links between electronic media use and attention problems in children and adolescents, say the authors, researchers have found evidence for small positive links between heavy electronic media use and mild attention problems among young people but have found only inconsistent evidence so far for a link between attention deficit hyperactivity disorder and media use. The authors point out that although video games, interactive websites, and multimedia software programs appear to offer a variety of possible benefits for learning, there is as yet little empirical evidence to suggest that such media are more effective than other forms of instruction. Vandewater is an associate professor in the Department of Human Development and Family Sciences at the University of Texas­Austin. Indeed, the stereotypical view of many Americans is that teenagers spend their lives immersed in electronic media. While adolescents are doing homework on the computer, with a wordprocessing program open for text, they are surfing the Internet. Simultaneously they are instant messaging with friends about events at school, about who likes whom, who "dissed" whom, or what a pain the homework assignment is. Meanwhile, television is on in the background, and they are listening to music on their iPods. At least some evidence confirms this picture, as Donald Roberts and Ulla Foehr describe in their article in this volume. Though concerns about the influence of media and technology on American youth are many and varied, especially prominent are fears that they impair cognitive development and academic achievement. Critics of television have long blamed the medium for various ills, including declines in standardized test scores, mental inactivity, and reduced attention and concentration. Some areas have generated a fair amount of theory and research; others, very little. Interestingly, evidence that contradicts or supports existing assumptions has often had little effect on proclamations, policy, and punditry on this topic.

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When asked about programs rated as educational/informative (E/I), children reported learning socio-emotional lessons more often than informational or cognitive lessons. In other words, the educational programs taught them more about emotions, such as overcoming fears and labeling different feelings, and about interpersonal skills, such as respect, sharing, and loyalty, than about science, history, or culture. This gender difference was attributed to the fact that girls reported liking such programs more and feeling more involved while viewing them. Finally, children learned more of these socio-emotional lessons from their favorite educational (E/I rated) than from their favorite entertainment-based programs. Nor did the study assess whether this learning persisted over time and more crucially, whether the lessons carried over into real life in some way. Half the children in the study (the control group) watched the main plot only, and half watched a version where the main plot was accompanied by a humorous subplot. The presence of the subplot interfered with the ability of younger children to understand the emotional event in the main plot, but not with the ability of older children. No matter what their age, children who viewed the humorous subplot tended to minimize the seriousness of the negative emotion. Children who viewed the earthquake episode with the humorous subplot judged earthquakes in real life as less severe than did those who viewed the episode without the subplot. This pattern was particularly strong among those who perceived the family sitcom as highly realistic. Early work demonstrates that regular viewing of Sesame Street can help preschoolers develop a fuller understanding of emotions and their causes. More recent research indicates that elementary school children, especially girls, can learn socialemotional lessons from television. Programs rated as E/I teach emotional lessons more effectively than do entertainment-based programs. Some experimental evidence suggests that children can transfer what they learn from emotional portrayals on television to their beliefs about emotional events in real life. This type of learning is greatest among those who perceive television as highly realistic. No research as yet addresses the longterm consequences of repeated exposure to electronic media on emotional development. It may be that children who are heavy viewers of, say, situation comedies develop a distorted perception of emotional problems as trivial and easily solved in thirty minutes or less. On the other hand, regular viewers of E/I programs may learn more about the intricacies of different types of emotional experiences because such portrayals are not routinely clouded in humor. Longitudinal studies- those that follow a cohort of individuals over a long period-are required to fully explore these issues. Emotional Empathy Learning to feel empathy or share emotions with others is part of what makes children effective social agents. Empathic children are more sensitive to others and are more likely to engage in socially desirable behavior in groups. Wilson Although children clearly share experiences with media characters, few researchers have studied this phenomenon. But they were less likely than the older children to engage in role-taking with the character, a skill that other studies have found to emerge around age eight and increase during the elementary school years. Children, for example, are more likely to share the emotions of a same-sex than an opposite-sex character. Children are more likely to experience empathy with plot lines and characters that they perceive as realistic. Thus, movies or television programs that feature younger characters in emotional situations that are familiar and seem authentic should produce the strongest empathy in youth. In the study, adults reported on their exposure to various types of fiction (romance, suspense novels, thrillers, science fiction, fantasy, domestic and foreign fiction) and nonfiction (science, political commentary, business, philosophy, psychology, self-help) print media. Media, Fear, and Anxiety Children can not only witness and share emotions experienced by media characters, but also respond directly to emotionally charged events depicted in the media. Classic Disney films such as Bambi, Snow White, and the Lion King can also be upsetting to very young children. Even programs not designed to be scary sometimes cause fear among younger age groups. Research shows that most preschoolers and elementary school children have experienced short-term fright reactions to the media. Research shows that most preschoolers and elementary school children have experienced shortterm fright reactions to the media.

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It is common for patients and their families to seek out other medical reasons that can occasionally factor in to becoming overweight. We do not recommend routinely testing for such reasons, but we do recommend a complete history and physical exam for any overweight or obese patient, including further evaluation for contributing causes as needed. Comorbidities include mild hypertension, dyslipidemias, insulin resistance, pseudotumor cerebri, sleep apnea, obesity hypoventilation syndrome, fatty liver, and orthopedic problems. Encourage lifestyle modifications, including healthy eating and active living (see pages 8­9). There are currently no intensive counseling programs available for children at Kaiser Foundation Health Plan of Washington. In the geographic area served, there may be limited options for older children and adolescents (see page 10). In the absence of community programs, we recommend following the same treatment strategy as for children and th th adolescents in the 85 ­94 percentile. Programs should target decreasing overall dietary energy intake, increasing levels of physical activity, and decreasing time spent in sedentary behaviors (such as screen time). The use of a behavior change counseling approach such as the 5As may allow clinicians to support patients in making changes to eating and physical activity behaviors. The 5As-Ask, Advise, Assess, Assist, Arrange-are an adaptation of motivational interviewing. Ask Attempt to engage all overweight and obese patients in conversation about their weight. Advise Advise patients to adopt healthier habits for eating and physical activity, using a clear and personalized manner. Talking points "In the short term, kids who are at an unhealthy weight can sometimes have difficulties with their peers, feel low self-esteem, be less physically fit, and experience a lower overall quality of life, compared with those who are at a healthy weight. Talking points "On a scale of 0 to 10, how ready are you to consider making a healthy change in your eating or physical activity? Arrange Arrange for follow-up contacts with the patient, either in person or by phone. As part of your well visit care, I will continue to track your weight and height, and let you know how you are doing. Healthy eating tips Parents are role models and can help to model healthy eating behaviors. Eliminate calories by drinking more water and less soda, fruit juice, and sports and other sugary drinks. Fruit juice is a less healthy choice than fresh fruit, as it adds excess calories without the benefit of the fiber that is found in fresh fruit. Encourage parents to talk with children and come up with a plan for making healthy food choices at school. Stock the house with healthy snacks, including fresh vegetables, fruit, string cheese, and yogurt. Encourage children to take an active role in choosing and helping to prepare healthy meals at home. Remember that healthy changes do not mean that some foods or drinks are "off limits. Nutritional advice A healthy diet: Emphasizes a variety of fruits, vegetables, whole grains, and fat-free or low-fat milk/milk products. Adolescents may be referred to the dietary recommendations in the Adult Weight Management Guideline. Families of overweight and obese children who are motivated to make dietary changes may be referred to a registered dietitian for individualized guidance on weight management. If the clinician or parent feels that the child or adolescent has demonstrated any signs of disordered eating such as bingeing, purging, or hiding food, it is best to consult with a registered dietitian and/or a Behavioral Health specialist as soon as possible. Increasing physical activity For children and adolescents aged 6 years and older, 30 to 60 minutes of physical activity per day is recommended. Choose activities that involve exercise for family outings (family hike, playground, swimming, skating). Decreasing sedentary activity Limit time spent watching television, using the computer, and playing video games to less than 1 hour a day total screen time. Remember that making changes does not mean that certain activities are "off limits.


  • https://www.cancer.org/content/dam/CRC/PDF/Public/8839.00.pdf
  • https://www.hhs.gov/sites/default/files/fy-2021-budget-in-brief.pdf
  • https://www.cdha.ca/pdfs/Profession/Journal/v43n2.pdf
  • https://www.dshs.wa.gov/sites/default/files/BHSIA/FMHS/DSHSTelehealthGuidebook.pdf
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