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Presentations of False Evidence A second problem concerns the tactic of presenting false evidence, which is often depicted as incontrovertible, and which takes the form of outright lying to suspects-for example, about an eyewitness identification that was not actually made; an alibi who did not actually implicate the suspect; fingerprints, hair, or blood that was not actually found; or polygraph tests that they did not actually fail. Supreme Court reviewed a case in which police falsely told the defendant that his cousin (whom he said he was with), had confessed, which immediately prompted the defendant to confess. The Court sanctioned this type of deception-seeing it as relevant to its inquiry on voluntariness but not a reason to disqualify the resulting confession. Although some state courts have distinguished between mere false assertions, which are permissible, and the fabrication of reports, tapes, and other evidence, which are not, the Supreme Court has not revisited the issue. From a convergence of three sources, there is strong support for the proposition that outright lies can put innocents at risk to confess by leading them to feel trapped by the inevitability of evidence against them. With regard to a specific variant of the problem, it is also worth noting that the National Research Council Committee to Review the Scientific Evidence on the Polygraph (2003) recently expressed concern over the risk of false confessions produced by telling suspects they had failed the polygraph (see also Lykken, 1998). Over the years, legal scholars have debated the merits of trickery and deception in the interrogation room. First, direct observations and self-report surveys of American police suggest that the presentation of false evidence is a tactic that is occasionally used. Yet in a position paper on false confessions, the Wisconsin Criminal Justice Study Commission (2007) concluded that ``Experienced interrogators appear to agree that false evidence ploys are relatively rare' (p. Second, it is instructive that in Great Britain, where police have long been prohibited from deceiving suspects about the evidence, relying instead on the investigative interviewing tactics described earlier, there has been no evidence of a decline in confession rates (Clarke & Milne, 2001; Gudjonsson, 2003; Williamson, 2006). In light of the demonstrated risks to the innocent, we believe that the false evidence ploy, which is designed to thrust suspects into a state of inevitability and despair, should be addressed. The strongest response would be an outright ban on the tactic, rendering all resulting confessions per se inadmissible-as they are if elicited by promises, threats, and physical violence (such a ban currently exists in England, Iceland, and Germany; suspects are differently protected in Spain and Italy, where defense counsel must be present for questioning). A second approach, representing a relatively weak response, would involve calling for no direct action, merely a change of attitude in light of scientific research that will lead the courts to weigh the false evidence ploy more heavily when judging voluntariness and reliability according to a ``totality of the circumstances. One way to achieve this compromise would be to curtail some variants of the false evidence ploy but not others-or in the case of some suspects but not others. As noted earlier, some state courts have distinguished between mere false assertions and the fabrication of reports, tapes, photographs, and other evidence, the latter being impermissible. False evidence puts innocents at risk to the extent that a suspect is vulnerable. By this criterion, which the courts would have to apply on a caseby-case basis, a confession produced by telling an adult suspect that his cousin had confessed, the ploy used in Frazier v. Minimization Tactics A third area of concern involves the use of minimization techniques (often called ``themes,' ``scenarios,' or ``inducements') that can communicate promises of leniency indirectly through pragmatic implication. While American federal constitutional law has long prohibited the use of explicit promises of leniency (Bram v. There is some legal support for the proposition that implicit promises of leniency are also prohibited in federal constitutional law (White, 1997), although a majority of states hold that a promise of leniency is only one factor to be considered in determining whether a confession is involuntary (White, 2003). These sources are: (1) the aggregation of actual false confession cases, the vast majority of which involved the use of minimization or explicit promises of leniency (Drizin & Leo, 2004; Leo & Ofshe, 1998; Ofshe & Leo, 1997a, 1997b; White, 2001); (2) basic psychological 123 Law Hum Behav research indicating, first, that people are highly responsive to reinforcement and make choices designed to maximize their outcomes (Hastie & Dawes, 2001), and second that people can infer certain consequences in the absence of explicit promises and threats by pragmatic implication (Chan & McDermott, 2006; Harris & Monaco, 1978; Hilton, 1995); and (3) experiments specifically demonstrating that minimization increases the rate at which research participants infer leniency in punishment and confess, even if they are innocent (Kassin & McNall, 1991; Klaver, Lee, & Rose, 2008; Russano et al. In light of the demonstrated risks to the innocent, we believe that techniques of minimization, as embodied in the ``themes' that interrogators are trained to develop, which communicate promises of leniency via pragmatic implication, should be scrutinized. Some law enforcement professionals have argued that minimization is a necessary interrogation technique (Inbau et al. As with the false evidence ploy, there are several possible approaches to the regulation of minimization techniques-ranging from the recommendation that no action be taken to an outright ban on minimization. Between these extreme positions one might argue that some uses of minimization but not others should be limited or modified. Minimization techniques come in essentially three forms: those that minimize the moral consequences of confessing, those that minimize the psychological consequences of confessing, and those that minimize the legal consequences of confessing (Inbau et al. One possible compromise between the two extreme positions noted above would be to permit moral and psychological forms of minimization, but ban legal minimization that communicates promises of leniency via pragmatic implication. With this distinction in mind, interrogators would be permitted, for example, to tell a suspect that he or she will feel better after confession (psychological minimization) or that he or she is still a good person (moral minimization), but not that the legal consequences of his actions will be minimized if he confesses. More research is thus needed to distinguish among the different tactics that interrogators are trained to use. Protection of Vulnerable Suspect Populations There is a strong consensus among psychologists, legal scholars, and practitioners that juveniles and individuals with cognitive impairments or psychological disorders are particularly susceptible to false confession under pressure.
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Most often these behavioral targets are physical aggression, property destruction/disruption, verbal aggression/disruption, elopement, and sexually inappropriate behavior. All of these behaviors tend to carry significant emotional valence for caretakers, underscoring the need for data rather than anecdotal reports. Data reveals behavioral trends that are difficult to deduce from non-data driven reporting. Effective treatment of psychiatric illness does not often result in immediate symptom cessation. It is incumbent on any prescribing clinician to not prescribe medication as a part of an overarching and ongoing treatment plan to simply and solely suppress behavior. Utilizing a biopsychosocial method to sort presentations into those that may truly represent psychiatric illness should be the initial goal, followed by empiric medication trials using data-driven feedback. It is critical for the clinician to maintain an open mind that permits constant reassessment of the information at hand. Recommendations for Policy Makers Systemic data collection must be done to better identify population prevalence and needs across systems. However, the population is getting increasing notice, and serious concerns have been raised regarding over-arrest, use of force, conditions of confinement, and access to appropriate services within the criminal justice systems. Their understanding of their legal rights when facing criminal charges, as well as their understanding of rules in correctional settings, can be limited-leading to further difficulties. Advocacy groups such as the Arc have developed strategies for system reform and attention to the unique needs of the population, through the establishment of their National Center on Criminal Justice and Disability. The competency-based workforce development program emphasizes a comprehensive biopsychosocial model, and provides opportunities for professional work to be reviewed and certified through a peer review process that includes the review of sample case conceptualization. The Vital Role of Specialized Approaches: Persons with Intellectual and Developmental Disabilities in the Mental Health System, August 2017 44 Table 3: Summary of Recommendations Designated inpatient units offer advantages of specialization and disadvantages of potential disparate, segregated treatment. Systems should review the balance between specialization and integration within psychiatric services, and recognize that even with integration, unique consultative supports may be needed for the treatment providers. The development of these collaborative efforts should include input from a variety of stakeholders and examine collaboration across all ages, including persons served in the child/adolescent, adult and older adult sectors. Perspectives of persons served, their families, and representative advocacy organizations will be critical in the development of the guidelines. There is much heterogeneity in this population, so generalizations and cookie-cutter approaches are risky. Understand that maximal self-direction and autonomy can be achieved with the right supports; assessments should be regularly updated with the expectation of improvement over stagnation. Trauma-Informed Care Person-Centered Care Behavioral Supports Pharmacologic Supports the Vital Role of Specialized Approaches: Persons with Intellectual and Developmental Disabilities in the Mental Health System, August 2017 46 Environmental Supports Gather information from all sources, especially direct service professionals, who can provide a wealth of information to inform program and planning. Peer partners, provider treatment networks, and a recognition of environmental precipitants to behavioral challenges can be helpful. The guidance should include coverage and reimbursement guidelines, as well as criteria for case reconciliation carried out by interagency health and human services bodies that is designed to parse eligibility, clinical, and financial responsibility for complex cases across multiple agency lines. The Vital Role of Specialized Approaches: Persons with Intellectual and Developmental Disabilities in the Mental Health System, August 2017 48 Recommendations for Policy Makers: Systemic data collection must be done to better identify population prevalence and needs across systems. Together there should be interagency outreach and collaboration with law enforcement, courts, and corrections to provide skilled de-escalation, diversion approaches, crossdiscipline education, linkages to services, and guidance in developing greater supports in justice system routine to accommodate persons with disabilities, as well as bridges to programs reflecting alternatives to incarceration. Although inpatient psychiatric hospitalization can be a needed response, a robust continuum of care and service delivery system that is increasingly sophisticated in working with this population is critical to maximizing the autonomy and community inclusion of these persons. This assessment outlines several recommendations for consideration, summarized in Table 3. Services designed to support these individuals can themselves be fractured or siloed and when stressors challenge the supports, there can be real shifts in behavior and need. Financing and policy alignment, as well as interagency cooperation and cross-training, will each be critical to maximally leveraging supports and services to best help individuals across populations. State Mental Health Authorities have a unique vantage point that requires a willingness to support individuals with serious mental illness along with the multiple comorbid conditions accompanying and compounded by mental illness. The Vital Role of Specialized Approaches: Persons with Intellectual and Developmental Disabilities in the Mental Health System, August 2017 50. CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc.
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The third multi-center clinical study evaluated PreservCyt Solution liquid Pap specimens from 1,647 subjects enrolled at six clinical sites. In performance calculations based on symptom status, subjects were classified as symptomatic if symptoms such as discharge, dysuria, and pelvic pain were reported by the subject. As many as three urethral swabs and a urine specimen were collected from male subjects and four endocervical swabs and a urine specimen were collected from female subjects. The commercially-available amplification assays were used as reference assays in this Aptima Combo 2 Assay clinical study. All performance calculations were based on the total number of Aptima Combo 2 Assay endocervical and male urethral swab and male and female urine specimens compared to a patient infected status algorithm for each gender. A negative culture and a single positive result by the amplified reference assay resulted in an inconclusive status. If all reference assay results were negative, the subject was designated not infected. Performance of the assay with endocervical swab and urine specimens from pregnant females was assessed in the clinical study. Specificity for endocervical swab and urine specimens was 100% (26/26) and 100% (26/26), respectively. Of the 646 asymptomatic subjects enrolled in the study, two were less than 16 years of age, 158 were between the ages of 16 and 20, 231 were between the ages of 21 and 25, and 255 were more than 25 years of age. Of the 818 symptomatic subjects enrolled in the study, 160 were between the ages of 16 and 20, 324 were between the ages of 21 and 25, and 334 were more than 25 years of age. Five specimens were collected from each eligible subject; one urine specimen, one patient-collected vaginal swab, one cliniciancollected vaginal swab, and two randomized endocervical swabs. Aptima Combo 2 Assay results were generated from the two vaginal swabs, one of the endocervical swabs, and an aliquot of the urine specimen. Specimen testing was conducted either at the site of subject enrollment or at an external testing site. All performance calculations were based on the total number of Aptima Combo 2 Assay patient-collected and clinician-collected vaginal swab results compared to a patient infected status algorithm. Culture was not used as a reference test since the Aptima Combo 2 Assay has already been evaluated against culture for other specimen types (refer to the Endocervical Swab, Male Urethral Swab, and Urine Specimen Clinical Study for details). Samples that were Aptima Combo 2 Assay positive and infected patient status negative. Subjects were designated with an unknown patient infected status if results were missing that prevented conclusive determination of infected status. Of the 5,782 Aptima Combo 2 Assay vaginal swab results from the multi-center clinical study, there was a small percentage (28, 0. Of the 1,647 available subjects, 1,288 were asymptomatic subjects and 359 were symptomatic subjects. Two specimens were collected from each eligible subject: one PreservCyt Solution liquid Pap specimen and one endocervical swab. PreservCyt Solution liquid Pap specimens were processed in accordance with the Aptima Combo 2 Assay 46 502487 Rev. After processing the PreservCyt Solution liquid Pap specimen with the ThinPrep 2000 Processor, the specimen was transferred into the Aptima Specimen Transfer Kit for testing with the Aptima Combo 2 Assay. The PreservCyt Solution liquid Pap specimens and endocervical swab specimens were tested with the Aptima Combo 2 Assay. Sensitivity and specificity for PreservCyt Solution liquid Pap specimens were calculated by comparing results to a patient infected status algorithm. The distribution of cervical sampling devices used in this clinical study according to clinical site is summarized in Table 4. Table 4: Summary of Cervical Sampling Devices Used in the PreservCyt Solution Liquid Pap Specimen Study Cervical sampling device Spatula/Cytobrush Broom-type Device Clinical Collection Site 1 0 100 2 124 0 3 475 0 4 287 0 5 57 240 6 364 0 Total 1307 340 Aptima Combo 2 Assay 47 502487 Rev. Table 7c: PreservCyt Solution Liquid Pap Specimen Clinical Study Patient Infected Status Results for C. Precision studies were conducted as part of the Endocervical Swab, Male Urethral Swab, and Urine Specimen Clinical Study and the PreservCyt Solution liquid Pap Specimen Clinical Study. Two (2) operators at each of the three sites performed one run per day on each of three days, totaling three valid runs per operator. Reproducibility when testing swab, urine, or PreservCyt Solution liquid Pap clinical specimens containing target organism has not been determined.
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However, the potential impact and effectiveness of data do not lie only in tracking more indicators or producing more surveys: the analysis and use of existing data to drive policy advocacy and programme design and implementation is vital. Indicators for this age group include: prevalence of low birthweight, stunting, wasting, and overweight rates of early, exclusive and continued breastfeeding timely introduction of complementary foods minimum meal frequency minimum diet diversity and minimum acceptable diet for ages 623 months vitamin A supplementation coverage, among others. In low- and middle-income countries, stunting and overweight among children under 5 are tracked closely at the national level, albeit with varying frequency. Some countries invest in annual data collection, while others collect data every three to five years. With current data, countries and regions can be compared, but sub-national data by household wealth and geographic and sex differentials, available in some countries, can Data on children under 5 Most data on nutrition for low- and middleincome countries relate to children under 5. In high-income countries, on the other hand, these nutrition indicators tend to be lacking for children under 5 since they are either not collected systematically or not routinely reported in a comparable way. However, including diet diversity indicators tracking how much and how often foods of various kinds are consumed, weighted by nutritional value in more surveys for a broader range of children would provide a better understanding of malnutrition. These indicators have been found to be powerful predictors of economic status and malnutrition (both stunting and wasting). Gathering reliable information on what children, adolescents and women eat is fraught with challenges. One example in data collection among school-age children is their limited cognitive ability to self-report their food intake. Many studies rely on questionnaires completed at school by children with little involvement of their parents. School-age children have been known to underreport or over-report their dietary intake, limiting the reliability of some data. Surveys of adolescents are hampered by their lack of motivation to respond to voluntary questionnaires and body image issues. Underreporting and misreporting of food intake are common among overweight and obese adolescents. Finally, food composition databases, which give (not always accurate) estimates for energy and macro- and micronutrient levels in common local foods, are either unavailable at the country level or not uniform across countries, making cross-country comparisons difficult. In many studies, global food composition databases are modified to accommodate countryspecific foods, again making comparisons unreliable. However, these data are based on self-reported height and weight in European countries, which could underestimate obesity rates because of social desirability bias. There is currently no standardized set of recommended indicators to be collected routinely through administrative systems, and no surveys at the country level. Dietary habits and food intake Another major gap is the lack of whole-of-diet data on what children, adolescents and women actually eat, and a dearth of data on micronutrient malnutrition. Without more knowledge on patterns and distributions of dietary habits, it is difficult to establish dietary priorities and goals. Our future depends on our ability to create a food system that supports healthy people and a healthy planet. Current food systems are outstripping the resources of the planet, while diets are resulting in global health crises of both over- and undernutrition. All this will be amplified by continued population growth and changes in dietary habits. The private sector is often seen as part of the problem, but I believe it can play a pivotal role in providing solutions. Take food processing for example: it can deliver high-quality food that extends the life of fruit and vegetables, thus reducing food waste. It can make healthy foods available all year round in environmentally challenged communities such as the Sahel region. In addition, when food is produced responsibly, the environmental impact of agricultural practices can be kept to a minimum or even be regenerative. Nearly all food consumed around the world is produced, processed or supplied by business, ranging from smallholder farmers and family farms to large, multinational companies. There is a clear business imperative to help meet the nutritional needs of children: malnutrition contributes to reduced productivity, and rising health, insurance and environmental costs, as well as vulnerable supply chains, which all have a direct impact on the bottom line.
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On an over-bed table, remove the contents of the Lumbar Puncture kit from the outer plastic packaging, leaving the contents wrapped in their sterile drape. Leave everything wrapped until the person performing the Lumbar Puncture is seated, and begins examining the subject. Feel the outside of the Lumbar Puncture kit (still wrapped up) to determine which end contains the spongy swabs. Turn this end toward the person performing the Lumbar Puncture and begin unwrapping the kit. When you grab an edge to unfold it, touch only the folded under portions of the outside of the wrapper. Remember, once they are gloved they can only touch the inside of the paper wrapper, and you can only touch the outside. Remember, you are the monitor for whether the person performing the Lumbar Puncture has broken sterility-usually by touching something not sterile with a sterile gloved hand. Wait until the person performing the Lumbar Puncture is finished preparing the kit and has started administering the lidocaine to the subject before you begin dropping items on the tray. After they start numbing up the subject, carefully, and maintaining sterility, unwrap and drop the 25g 1 1/2" deep infiltration needle, spinal introducer and the Sprotte spinal needle onto the Lumbar Puncture tray. With the spinal needle and introducer, it often works best to pinch the item through the clear plastic portion of the package firmly, while removing the paper strip from the other side. One way is to take hold of the two sides of the packaging with the thumb and forefinger of each hand and pull them apart making sure the opening is facing down toward the tray. Again remember, do not drop any packaging onto the tray, do not touch the tray with your hand, and do not let the item touch the outside of the packaging on its way to the tray. Start with 3 syringes, but be ready to add more if the person performing the Lumbar Puncture needs them. Occasionally, the person performing the Lumbar Puncture will need to use more lidocaine to numb up a particular spot a little more or if they need to move to another spot entirely. In either case, they will need another 3 cc syringe and needle (packaged together and sterile). Open the package as you would a sterile syringe by pulling open the two sides of the packaging without touching the inside or the syringe, but hold it upright instead, so that the person performing the Lumbar Puncture can grab the syringe without touching the outside of the packaging. Then, you will need to take a bottle of lidocaine (check the expiration date) and swab the top of it with an alcohol wipe. Next, hold the bottle upside down and at a slight angle toward the person performing the Lumbar Puncture so that they can plunge the needle into the bottle and extract some lidocaine without touching you or the bottle. Open it the same way as the syringe and needle example above, by holding open the package so the person performing the Lumbar Puncture can grab the gauze without touching you or the package. One usually waits until this time because it is easier to supply all of the sterile items without gloves on. As the person performing the Lumbar Puncture fills the 7 cc collection tubes (or 5 cc syringes if using suction method), they will place them at the far end of the Lumbar Puncture kit, far from them, near to you. This is a gray area as far as sterility goes; however, we try to keep it as sterile as possible. Hand the first full tube to the aliquoter; have them aliquot 1 mL for red and white cell count into the 2 mL cryogenic vial and 1 mL for total glucose and protein into another 2 mL cryogenic vial. The two 2 mL cryogenic vials will then need to be shipped to your local laboratory for testing. All visible traces of iodine should be cleaned from the skin (use 2 wet washcloths), the skin dried, and the Band-Aid applied over the puncture site. After they have made the subject more comfortable, they will remove the sharps from the kit. They do this because they are more familiar with the kit and where they put all the sharps and how many there are, etc. After the study ends and the subject has left, wash the over-bed table down with a bleach wipe. Then inject lidocaine using the pattern of a square - first the center and then to all 4 corners. Again, use the same pattern - be sure to draw the needle back out nearly all the way out to change direction.
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Darke S, Sims J, McDonald S, Wickes W: Cognitive impairment among methadone maintenance patients. Adv Alcohol Subst Abuse 1984; 4:8996 [B] Treatment of Patients With Substance Use Disorders 253 Copyright 2010, American Psychiatric Association. Cami J, de Torres S, San L, Sole A, Guerra D, Ugena B: Efficacy of clonidine and of methadone in the rapid detoxification of patients dependent on heroin. Spencer L, Gregory M: Clonidine transdermal patches for use in outpatient opiate withdrawal. Nyswander M, Winick C, Berstein A, Brill I, Kauger G: the treatment of drug addicts as voluntary outpatients: a progress report. Arch Gen Psychiatry 1987; 44:281284 [C] Treatment of Patients With Substance Use Disorders 255 Copyright 2010, American Psychiatric Association. Stimmel B, Cohen M, Sturiano V, Hanbury R, Korts D, Jackson G: Is treatment for alcoholism effective in persons on methadone maintenance? American Thoracic Society: Diagnostic standards and classification of tuberculosis. Suffet F, Brotman R: A comprehensive care program for pregnant addicts: obstetrical, neonatal, and child development outcomes. Psychiatr Ann 2003; 33:585592 [F] Treatment of Patients With Substance Use Disorders 257 Copyright 2010, American Psychiatric Association. Substance Abuse and Mental Health Services Administration: Results from the 1992 National Household Survey on Drug Abuse: Main Findings 1992. Substance Abuse and Mental Health Services Administration: Results From the 2004 National Survey on Drug Use and Health: National Findings. Centers for Disease Control: Alcohol-related mortality and years of potential life lost: United States, 1987. National Institute on Drug Abuse: National Pregnancy and Health Survey: Drug Use Among Women Delivering Livebirths. Centers for Disease Control: Current trends: statewide prevalence of illegal drug use by pregnant women: Rhode Island. Centers for Disease Control: the Health Benefits of Smoking Cessation: A Report of the Surgeon General. Lerman C, Patterson F, Berrettini W: Treating tobacco dependence: state of the science and new directions. Clin Chest Med 2002; 23:125 [F] Treatment of Patients With Substance Use Disorders 259 Copyright 2010, American Psychiatric Association. Centers for Disease Control: the Health Consequences of Involuntary Smoking: A Report of the Surgeon General. Office of Health and Environmental Assessment: Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. Fagerstrцm K: the epidemiology of smoking: health consequences and benefits of cessation. Bauman A, Phongsavan P: Epidemiology of substance use in adolescence: prevalence, trends and policy implications. Centers for Disease Control and Prevention: Youth tobacco surveillance: United States, 19981999. Berglund M, Ojehagen A: the influence of alcohol drinking and alcohol use disorders on psychiatric disorders and suicidal behavior. Farrell M, Howes S, Bebbington P, Brugha T, Jenkins R, Lewis G, Marsden J, Taylor C, Meltzer H: Nicotine, alcohol and drug dependence, and psychiatric comorbidity: results of a national household survey. Ann Epidemiol 2003; 13:230 237 [D] Treatment of Patients With Substance Use Disorders 261 Copyright 2010, American Psychiatric Association. Kalant H: Adverse effects of cannabis on health: an update of the literature since 1996. Zammit S, Allebeck P, Andreasson S, Lundberg I, Lewis G: Self reported cannabis use as a risk factor for schizophrenia in Swedish conscripts of 1969: historical cohort study. Substance Abuse and Mental Health Services Administration: Preliminary Results From the 1997 National Household Survey on Drug Abuse.
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If trust issues are substantial, some cases may require extra time; however, there should be an expectation that communication will be bi-directional, with birth parents consulted regarding the day-to-day care of the child. Child-related communication between the two sets of families should begin as soon after removal as is practical, particularly with young children under the age of three. Case workers are expected to assist in the coparenting relationship by ensuring that the parents have an initial meeting and communication between the birth parents and caregivers regularly occurs. Coparenting facilitates the creation of a sensitive transition plan when the family is reunified or when another permanency plan is adopted. The transition plan should be part of the case plan and include tasks that allow for the child to retain a relationship with the caregiver and birth parent. Experience has shown that the newly reunified parent will be more open to continued contact if a positive coparenting alliance had developed. Visitation, communication, and other forms of contact should be addressed as the transition plan begins and should be monitored on an ongoing basis with the parties, no matter the permanency goal. The diligent engagement of all involved parties in the coparenting alliance supports the shared commitment to care for the child. Judges should encourage caregivers to ask the parent questions about the child (What is his favorite food? Judges should ensure that the caregivers have all the information and court documentation necessary to care for the child (medical records, school records, court orders). Familycentered practice, along with federal law, requires a rigorous examination of extended family for possible placement. When family outside of the state is identified, the Interstate Compact on the Placement of Children is used as the process for placement of the child with the relative. When relatives are identified within the state yet out of the circuit with jurisdiction, outof-county services are required. Most of the rules and procedures pertain to requirements of the department and occur outside of court hearings and do not relate strictly to actions for judges. When a child relocates to a county other than the county of jurisdiction or when supervision services are needed in another county, specific actions are required to ensure the safety and well-being of the child and to coordinate the request for supervision and services and are required whether or not the child has been adjudicated dependent. If after the completion of a home study, the court in the sending county orders the child into the placement, the contracted service provider in the sending county must immediately send a referral for out-of-county supervision to the contracted service provider in the receiving county. When placement of a child in a relative or non-relative home is being considered, the criminal, delinquency, and abuse/neglect history check and home study and other requirements must be met. If a child is in shelter status with a relative or non-relative, a criminal, delinquency, and abuse/neglect history check and an on-site inspection of the proposed placement must be requested by the worker in the county of jurisdiction and performed by a worker in the receiving county prior to placing the child. The final decision on whether to recommend to the court for or against the placement of the child is made by the receiving county, unless placement is courtordered without an opportunity for the receiving provider to provide input prior to the placement decision. Once the court has ordered placement, the receiving county must accept the placement as approved. Cases cannot be closed and jurisdiction cannot be transferred to the contracted service provider in the receiving county prior to the following: · Prior to recommending case closure to the court, the worker in the county of jurisdiction must inform the worker in the receiving county of the planned action and ensure that the receiving county has an opportunity to comment on the advisability of the planned action. When a child is placed in another county: Prior to completion of the homestudy, review the case frequently to ensure that the homestudy request has been sent to the receiving county. If a personal appearance is not possible, then arrange for the caregiver to appear electronically. At each regularly scheduled hearing, inquire as to the status of the homestudy request. To avoid delays in permanency for the child, order that the department request a preadoptive homestudy on the child. Remember that young children placed out-of-county are more difficult to reunify because visitation is complicated by the placement. Appointment shall occur at the earliest possible time in any civil or criminal abuse, neglect, or abandonment judicial proceeding. The court shall encourage the Statewide Guardian ad Litem office to provide greater representation to those children who are within 1 year of transferring out of foster care. The trial court "shall consider and evaluate all relevant factors, including, but not limited to. If the court properly considers and evaluates the recommendation, however, "[t]he trial court may reject the recommendations of the Guardian ad Litem and give weight to expert testimony in consideration of all the evidence.
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In the most recent year for which surveys are available for global monitoring, at all poverty lines there are countries with the incidence of impoverishing health spending below 1% (Figure 2. But there are also countries with incidence above 3% in the Region of the Americas at all poverty lines, above 10% in the African Region at the $1. The incidence of impoverishment due to out-of-pocket health spending does not indicate how poor those pushed into poverty by out-of-pocket health spending are. Nor does it capture the impact of out-of-pocket health spending on households that are already below the poverty line even in the absence of out-of-pocket health spending. But the amount by which out-of-pocket health spending pushes people below the poverty line does capture that impact, shown in the change in the poverty gap due to out-of-pocket health spending. For households already below the poverty line, the change in the poverty gap corresponds to the total out-of-pocket health payment. For households that are impoverished by out-of-pocket health spending, the gap corresponds to the amount that exceeds the shortfall between the poverty line and total consumption. And for households whose consumption is above the poverty line after accounting for out-of-pocket health spending, the gap is zero. There is important variation in the poverty gap increase due to out-of-pocket health spending in the most recent year for which estimates are available for global monitoring (Figure 2. In all regions and at all poverty lines, there are countries where out-of-pocket health spending contributes only marginally (by less than 0. The countries in the 90th percentile, by contrast, saw marked changes, ranging, at the $1. Source: Based on Global monitoring report on financial protection in health 2019 (4). This means that out-of-pocket health spending was adding considerably to the number of poor people and the depth of poverty in those countries. In 2000, the world population impoverished by out-of-pocket health spending lived primarily in low-income countries. Between 2000 and 2015, the concentration of the world population impoverished by outof-pocket health spending shifted to lowermiddle-income countries at the $1. In high-income countries, the number of people impoverished by out-of-pocket spending at the relative poverty line of 60% of median daily per capita consumption or income increased by an average of 3% a year, with the fastest increase, 7. For the 56 low- or lower-middle-income countries for which surveys are available for two or more years, the population-weighted median annual changes in the poverty gap increase attributable to out-of-pocket health spending were 0. At the 60% relative poverty line, for the 90 countries for which surveys are available for two or more years, the population-weighted median annual change in the poverty gap increase was 0. Thus, the increase in the depth of poverty due to out-of-pocket health spending has been falling at all poverty lines, though only marginally at the relative poverty line. In summary, indicators of financial protection point to mixed improvements between 2000 and 2015 at the global and regional levels and across income groups in protecting people from incurring financial hardship when spending out of pocket on health. The number of people and percentage of the population impoverished by out-of-pocket health spending at the $1. Sharp decreases in the number and percentage of people impoverished by out-of-pocket health spending occurred only in low-income countries, 20002015 $3. Global and regional trends in financial protection · 39 Who experiences financial hardship? Rural populations tend to be poorer and less healthy, and health systems in rural areas tend to be weaker. Geographic distance and less developed transport services in rural areas pose additional challenges in access to services. Across countries, for the most recent year for which estimates are available for global monitoring, the median share of the population spending more than 10% of the household budget on health is marginally higher in urban areas, while the median share of the population spending more than 25% of the household budget on health is marginally higher in rural areas (Table 2. The population-weighted median using the share of the rural population in each country confirms this gap. On average, the incidence of impoverishing health spending (weighted and unweighted) is higher in rural areas at both absolute poverty lines of $1. In high income countries, the incidence of catastrophic health spending is higher in rural areas than in urban ones, while in low-income countries the opposite is observed.