Wayne E. Cascio, MD
- Professor of Cardiovascular Science and Medicine
- Vice-Chairman, Department of Cardiovascular Sciences
- Brody School of Medicine
- Director of Research, East Carolina Heart Institute
- East Carolina University
- Chief of Cardiology, Pitt County Memorial Hospital
- Greenville, North Carolina
However asthma usmle cheap 500 mcg advair diskus mastercard, the material noted above serves as the underpinnings to most behavioral treatments for individuals with developmental disabilities asthma rash order genuine advair diskus online. The following sections describe how these basic principles asthma treatment herbal proven advair diskus 500 mcg, in concert with other procedures asthma treatment for children under 5 purchase advair diskus paypal, form the basis of the treatment for challenging behavior and skill acquisition in children with developmental disabilities asthma treatment 2015 buy advair diskus with mastercard. Functional assessments are procedures designed to gather information, generate hypotheses about behavioral function, and determine the causal factors contributing to behavior issues. Relevant procedures include interviews; rating scales; and open-ended, question-and-answer forms. The following sections explain each category of functional assessment in more detail. Indirect assessment may include an initial evaluation in which a therapist gathers demographic information, including the chief areas of complaint. Therefore, it is important for a clinician to understand the relative influence of these events on the target behavior. The primary way for determining those relations is through a process called functional assessment. Assessment of Challenging Behavior As discussed earlier in this chapter, behavioral treatments address the function of behavior rather than its topography; that is, behavioral treatments are generally developed to address the "purpose" that is served by that target behavior. Of course, these contingencies typically develop incidentally and over the course of time. A similar Indirect Assessment 694 Roane, Sullivan, Martens, and Kelley provide alternative ratings for statements, such as "My child engages in much more challenging behavior than would be normal in a school. Scoring the ratings can help draw conclusions about why the challenging behavior occurs. It is a structured interview that includes 11 sections that purport to quickly identify putative functions of challenging behavior. The interview provides a guide for the interviewer across multiple content areas: 1) developing a description of the behavior; 2) identifying settings events, antecedents, and consequences for maladaptive behavior; 3) identifying how efficient the maladaptive behavior is, alternative behavior, and communicative ability; 4) identifying reinforcers; and 5) describing the history of previous interventions. After completing the interview procedures, the interviewer determines the operational definitions of challenging behaviors, environments in which the responses occur, antecedent and consequent conditions influencing the behavior, and other information that will help select an intervention. First, indirect assessment relies on accurate recall of past events and faithful ratings of those events. Descriptive assessment, on the other hand, focuses on observation of the behavior in vivo and data collection of the target behavior under naturalistic environmental conditions. Second, indirect procedures are removed in time and place from the occurrence of the target behavior. Descriptive assessment allows for real-time observation of behavior while interacting with the environment. Descriptive assessments provide information about the conditions under which the target behavior does and does not occur and the order in which a series of challenging behaviors occur. Specifically, they arranged a number of observations designed to experimentally test a specific reinforcement contingency. In the social disapproval (or attention) condition, the researchers ignored the child unless he or she displayed challenging behavior, in which case they provided attention to the child in the form of statements of concern or disapproval. This condition assessed the role of positive reinforcement in the occurrence of a challenging behavior. A second condition, academic demand, was conducted in which the researchers presented academics to the child and provided a break from instructions (in the form of removal of the academic material) contingent on the occurrence of the challenging behavior. An alone condition was also conducted in which the researchers observed a child who was alone in a room through an observation window. In this condition, there were no programmed contingencies in place for the challenging behavior. In the control condition, the child 1) had access to preferred items (to reduce the likelihood of automatically reinforced challenging behavior), 2) had access to adult attention (to reduce the likelihood of positively reinforced challenging behavior), and 3) had no academic demands presented (to reduce the likelihood of negatively reinforced challenging behavior). The relative benefit of this type of functional assessment is that the clinician has direct control over the contingencies that are influencing the behavior, which permits a more detailed level of analysis and hypothesis testing (Vollmer, Roane, & Rone, 2012). These results were important because they validated the hypothesis presented by Carr (1977) regarding the potential role of operant contingencies in the occurrence of a challenging behavior. They also indicated that there were idiosyncratic differences regarding the reason that a challenging behavior occurred across participants. The functional analysis procedure developed by Iwata and Behavioral Therapy 695 colleagues (1994) has been validated in hundreds of studies addressing many different types of challenging behavior (Beavers, Iwata, & Lerman, 2013; Hanley, Iwata, & McCord, 2003). It has also proven to be an adaptable model of assessment, with procedural modifications made to decrease time expenditures (Falcomata, Muething, Roberts, Hamrick, & Shpall, 2016), to develop novel conditions (McCord, Thompson, & Iwata, 2001), and to be implemented in nonclinical settings by individuals other than trained researchers (Martens, Gertz, Werder, & Rymanowski, 2010). Moreover, the advent of functional analysis has resulted in an increased use of reinforcement-based treatments for challenging behaviors and a decreased reliance on punishment-based procedures (Didden, Duker, & Korzilius, 1997). Nevertheless, the functional analysis procedure is not appropriate for all populations or settings. As a result, a number of alternative procedures have been developed to assess the role of various reinforcement contingencies on the occurrence of challenging behavior (Martens et al. A control condition and four test conditions (attention, tangible, demand, and ignore) were implemented in a multi-element, single-case design. The control condition (toy play) consisted of a therapist delivering near continuous attention to Roger, in the absence of any instructions, while he had access to preferred toys. In the demand condition, the therapist delivered academic instructions to Roger, and, contingent on aggression, a brief break was provided. This assessment approach is based on the analog functional analysis procedure developed by Iwata, Dorsey, Slifer, Bauman, and Richman (1994). In a functional analysis, the individual is exposed to a number of "test" conditions. In each of these conditions, the clinician creates a situation that mimics those from the natural environment that might be associated with an increased probability of severe maladaptive behavior. These test conditions are compared with a control condition that is specifically arranged to promote low levels of maladaptive behavior. The child is exposed to a series of direct observations under the various test (and control) conditions. Those conditions associated with the most elevated and persistent occurrences of maladaptive behavior (compared with the control condition) are indicative of a maintaining reinforcement contingency, or the "function" of the behavior. Beavers, Iwata, and Lerman (2013) reviewed more than 400 published studies that had implemented a functional analysis to identify the reinforcement contingencies that maintained challenging or maladaptive behavior. Although most of those studies (approximately 75%) involved children as participants, the methods were also replicated with adult and geriatric populations. Additional generality for this approach was suggested by the use of functional analysis across individuals with and without intellectual and developmental disabilities, and the studies reviewed addressed a large range of challenging behavior types. Across all reviewed studies, Beavers and colleagues found differentiated results. Application to Practice the functional analysis method is effective for identifying the conditions that are most likely to maintain the occurrence of challenging behavior. This link between assessment and treatment is important and somewhat unique, in that the functional assessment informs treatment development by providing information on what environmental variables can be altered in treatment. For example, if the functional analysis indicates a negative reinforcement function, we know that the individual is motivated to use a challenging behavior to avoid nonpreferred activities. Given this knowledge, the therapist can develop a treatment that provides access to this reinforcer for some other, appropriate form of behavior. Each data path represents the corresponding test (attention, demand, tangible, ignore) and control (toy play) conditions. Here the therapist restricted access to preferred toys and, following the occurrence of aggression, allowed Roger to continue playing with his toys. For the purpose of this discussion, the focus is on treatments developed to address the positive reinforcement function; procedures for addressing multiple functions and combining interventions are discussed elsewhere (Call, Wacker, Ringdahl, & Boelter, 2005; Neidert, Iwata, & Dozier, 2005; Scheithauer, Mevers, Call, & Shresbury, 2017). In summary, conducting a functional assessment is a valuable first step in developing an effective behavioral treatment for challenging behaviors displayed by individuals with developmental disabilities. The primary benefit of conducting a functional assessment is that it permits one to test specific hypotheses about the potential contingencies that could be affecting the occurrence of a target behavior, thereby determining the function or purpose that the behavior serves. Once known, behavioral treatments can be developed to specifically intervene on that function. Following the logic of intervening on the environmental variables that are identified in the functional assessment, a basic component of many behavioral treatments is extinction. Technically speaking, extinction involves interruption of an existing relationship between a response and the maintaining reinforcer. Using this procedure, aggression would no longer "pay off" and, over time, the behavior should decrease. For example, buying a drink from a vending machine could present an opportunity for extinction. That is, if you put money in the machine and pressed a button for your drink of choice, your behavior would be reinforced by delivery of the drink. If, however, the drink does not appear at the bottom of the machine, your drink selection response would have encountered extinction. Extinction is used as a component of many treatments for challenging behaviors displayed by individuals with developmental disabilities. However, it is rarely used in isolation because extinction alone can result in a number of side effects. If you place your money in the machine, press the button for drink A, and it does not come out, you tend to engage in a number of other responses. After a while, you might vary your responding and press the button for drink B, then drink C, and so on. Some people might become angry and hit the machine or swear Behavioral Therapy 697 aloud. You might, however, try the machine again the next day or a week later and, if it was still malfunctioning, go through this same series of behaviors. When extinction is introduced, there is an increased likelihood of response frequency, response intensity, response variation, and the emergence of emotional behavior or other forms of maladaptive behavior such as aggression. Likewise, the effect of periodically attempting a response that has encountered extinction, such as trying the vending machine after a week, is common and is referred to as spontaneous recovery. A review of published data on the use of extinction showed that behaviors resembling an extinction burst only occur in about one third of cases (Lerman & Iwata, 1995). The potential for extinction bursts is one reason that extinction is rarely implemented as the only component of a behavioral treatment. A second reason is that extinction alone does not permit the development of an alternative response to replace the challenging behavior. In this case, extinction involved disrupting the relationship between aggression and providing access to preferred activities. A limitation, however, is that this procedure did not include a mechanism by which Roger could access his preferred activities. Differential Reinforcement Differential reinforcement is a broad category of treatments that essentially involve reinforcing behaviors that are alternatives to the challenging behaviors. For example, an individual might be taught to engage in a manual sign to access reinforcement while the challenging behavior is placed on extinction. There are a number of different ways in which a differential reinforcement contingency can be arranged. This section describes three procedures that are used most commonly in the treatment of challenging behaviors for individuals with developmental disabilities: differential reinforcement of other behavior, differential reinforcement of alternative behavior, and differential reinforcement of incompatible behavior. This procedure teaches the individual that challenging behavior "no longer works" and that not engaging in that behavior produces access to reinforcement. Functional Communication Training Children with developmental disabilities often do not imitate or ask for information, may exhibit repetitive or stereotypic behavior, may pay little attention to social cues, and may have limited communication skills (Smith, 2001; Wehmeyer, Brown, Percy, Shogren, & Fung, 2017). As a result, these children may fail to acquire or may be delayed in acquiring key or pivotal skills such as functional communication, object discrimination, imitation, simple speech, self-care, and/ or playing with peers. This communication response is also referred to as a "mand" since it is used to "command" or ask for the reinforcer (Skinner, 1957). Engagement in the communication response is reinforced while engaging in challenging behavior is placed on extinction in the natural environment. Specifically, they taught Roger to say three different communication "frames" ("May I have The color-coded scripts could then be taken by Roger into different settings as common stimuli, thereby promoting generalization of communication. Also using the presence of the color-coded scripts as stimuli, the team promoted the maintenance of communication by decreasing the amount of time during which the scripts were present as signals for the reinforcement of communication using a multiple-schedule approach (Fuhrman et al. A multiple schedule is a procedure in which two discriminative stimuli are used to signal to the individual the various contingencies that are in place during treatment. That is, during periods when one or more of the colorcoded scripts were present, communication was reinforced with access to the item. During other times when the color-coded scripts were not present, communication was not reinforced and Roger had to wait to ask for desired items. If Roger responded correctly on four of five trials, then the delay between presentation of the script and the model was increased by 3 seconds. Training continued until Roger responded correctly before the model on four of five trials over two consecutive sessions for each communication frame. After Roger was able to say each script accurately, the therapist began script fluency training. Roger was told, "Say the card correctly as fast as you can," and the therapist presented each flash card. Fluency training continued until Roger was no longer able to beat his previous time for saying all 15 flashcard scripts. Following script acquisition and fluency training, the therapist began teaching Roger to communicate for desired items using the scripts in different situations. The therapist began each session by placing the corresponding script in front of Roger, displaying a desired item out of reach. If Roger did not request the item, the therapist prompted a response by saying, "Say the card.
Prescription stimulant medication misuse: Where are we and where do we go from here Repetitive bilateral arm training with rhythmic auditory cueing improves motor function in chronic hemiparetic stroke asthma symptoms vs allergies discount 250mcg advair diskus amex. Psychostimulant drug effects on glutamate asthma zenhale generic 500 mcg advair diskus amex, Glx asthma treatment algorithm 2014 250 mcg advair diskus free shipping, and creatine in the anterior cingulate cortex and subjective response in healthy humans asthma headache purchase advair diskus with paypal. Reductions in acetylcholine and nicotine binding in several degenerative diseases asthma definition uncanny order advair diskus once a day. Frontal brain asymmetry as a biological substrate of emotions in patients with panic disorders. Attention-deficit/hyperactivity disorder and the substance use disorders: the nature of the relationship, subtypes at risk, and treatment issues. 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Fluctuations in nucleus accumbens dopamine concentration during intravenous cocaine selfadministration in rats. Common and distinct patterns of grey-matter volume alteration in major depression and bipolar disorder: Evidence from voxel-based meta-analysis. Tourette syndrome: Prediction of phenotypic variation in monozygotiz twins by caudate nucleus D2 receptor. Focal atrophy of the hypothalamus associated with third ventricle enlargement in autism spectrum disorder. Positron emission tomography reveals elevated D2 dopamine receptors in drug-naive schizophrenics. Genome-wide association study of major depressive disorder: New results, meta-analysis, and lessons learned. Combination of volume and perfusion parameters reveals different types of grey matter changes in schizophrenia. Evidence of association between gamma-aminobutyric acid type A receptor genes located on 5q34 and female patients with mood disorders. 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A preliminary study of the effects of electroconvulsive therapy on regional brain glucose metabolism in patients with major depression. A positron emission tomography study of norepinephrine transporter occupancy and its correlation with symptom response in depressed patients treated with quetiapine xr. Decreased cerebral blood flow in the primary motor cortex in major depressive disorder with psychomotor retardation. Gray-matter relationships to diagnostic and transdiagnostic features of drug and behavioral addictions. Prediction of antidepressant response to milnacipran by norepinephrine transporter gene polymorphisms. Postreceptor pathways for signaling transduction in depression and bipolar disorder. Electroconvulsive therapy, depression, the immune system and inflammation: A systematic review. Whole genome sequencing resource identifies 18 new candidate genes for autism spectrum disorder. Genetic and environmental risk factors for illicit substance use and use disorders: Joint analysis of self and co-twin ratings. Investigation of short tandem repeats in major depression using whole-genome sequencing data. Nucleus accumbens feedforward inhibition circuit promotes cocaine self-administering. Reduced risk of Alzheimer disease in users of antioxidant vitamin supplements: the Cache County Study. Target-specific deep brain stimulation of the ventral capsule/ventral striatum for the treatment of neuropsychiatric disease. Brain-derived neurotrophic factor serum levels in heroin-dependent patients after 26 weeks of withdrawal. Sildenafil enhances neurogenesis and oligodendrogenesis in Ischemic brain of middle-aged mouse. Sildenafil (Viagra) induces neurogenesis and promotes functional recovery after stroke in rats. Gene-based analyses reveal novel genetic overlap and allelic heterogeneity across five major psychiatric disorders. Association of intron 1 variants of the dopamine transporter gene with schizophrenia. Muscarinic and nicotinic cholinergic mechanisms in the mesostriatal dopamine systems. Serotonin transporter gene polymorphisms and selective serotonin reuptake inhibitor tolerability: Review of pharmacogenetic evience. Modulation of plasticity in human motor cortex after forearm ischemic nerve block. Gender similarities and differences: the prevalence and course of alcohol and other substance-related disorders. Gender differences in verbal and visuospatial working memory performance and networks. Deficits in gray matter volume are present in schizophrenia but not bipolar disorder. Disruption of cocaine and heroin selfadministration following kainic acid lesions of the nucleus accumbens. Buprenorphrine-induced changes in mu-opioid receptor availability in male heroin-dependent volunteers: A preliminary study. It is important to understand that while these disorders are individually rare, genetic alterations underlie almost half of developmental disabilities. Medical treatment is increasingly available for a number of these disorders, though often at great cost. Her parents became very concerned because their older son, Andrew, had died in infancy after an episode of lethargy and seizures was followed by coma, although no specific diagnosis had been made. As a result, girls are less likely to be affected by X-linked disorders than boys, and, when affected, they generally have less severe symptoms. Katy was placed on a low-protein diet and given a medicine to provide an alternate pathway to rid the body of ammonia, and she has done well. Now age 7, she appears to have a mild nonverbal learning disability resulting from her prior metabolic crises; if Katy had been left untreated, she would probably not be alive. Thought Questions: How often do we miss a genetic diagnosis as a cause of developmental disabilities There are many cell types: nerve cells, muscle cells, white blood cells, liver cells and skin cells, to name a few. There are 23 pairs of chromosomes and about 20,000 proteincoding genes that collectively make up the human genome. These genes are responsible for our physical attributes and for the biological functioning of our bodies. When there is a defect within this system, the result may be a genetic disorder, often causing developmental disabilities. There can also be a microdeletion of a number of closely spaced or contiguous genes within a chromosome. Microdeletions may have varied expression depending on stochastic (randomly determined) and environmental processes, as well as on genetic effects, with these factors potentially acting alone or in combination (Bertini et al. In each human cell, the Genetics Underlying Developmental Disabilities 5 there are normally 46 chromosomes. Typically, one chromosome in each pair comes from the mother and the other from the father. Egg and sperm cells, unlike all other human cells, each contains only 23 chromosomes. The 23rd pair consists of the X and Y chromosomes and are called the sex chromosomes. The Y chromosome, which is involved in male sex determination and development, is one-third to one-half the size of the X chromosome, has a different shape, and has far fewer genes. The prenatal development of a human being is accomplished through cell division, differentiation into different cell types, and movement of cells to different locations in the body. In mitosis, or nonreductive division, 2 daughter cells, each containing 46 chromosomes, are formed from 1 parent cell. In meiosis, or reductive division, 4 daughter cells, each containing only 23 chromosomes, are formed from 1 parent cell. The ability of cells to continue to undergo mitosis throughout the life span is essential for proper bodily functioning. Cells divide at different rates, however, ranging from once every 10 hours for skin cells to once a year for liver cells. This is why a skin abrasion heals in a few days but the liver may take a year to recover from hepatitis. By adulthood, some cells, including neurons and muscle cells, appear to have a significantly decreased ability to divide. One of the primary differences between mitosis and meiosis can be seen during the first of the two meiotic divisions. During this cell division, the corresponding chromosomes line up beside each other in pairs. Unlike in mitosis, however, they intertwine and may "cross over," exchanging genetic material. Although this crossing over (or recombination) of the chromosomes may result in disorders. Some of the variability among siblings can also be attributed to the random assortment of maternal and paternal chromosomes during the first of the two meiotic divisions. Throughout the life span of the male, meiosis of the immature sperm produces spermatocytes with 23 chromosomes each. These cells will lose most of their cytoplasm, sprout tails, and become mature sperm. In the female, meiosis forms oocytes that will ultimately become mature eggs in a process called oogenesis. By the time a girl is born, her body has produced all of the approximately 2 million eggs she will ever have. When chromosomes divide unequally, a process known as nondisjunction occurs; as a result, 1 daughter egg or sperm contains 24 chromosomes and the other 22 chromosomes. Meiotic nondisjunction, particularly in oogenesis, is the most common mutational mechanism in humans responsible for chromosomally atypical fetuses. Usually, these cells do not survive, but occasionally they do and can lead to the child being born with too many chromosomes. Notably, the most commonly found trisomy in miscarriages is trisomy 16, and embryos with trisomy 16 are never carried to term (Nussbaum, McInnes, & Willard, 2016). The chromosome 16 contains so many genes important for normal development that its disruption is incompatible with life. Conversely, trisomies 13, 18, and 21 are the most commonly observed full trisomies at birth (Mai et al.
Treatment involves the administration of caffeine asthma symptoms webmd purchase advair diskus in united states online, which has been shown to reduce the incidence of apnea and decrease the risk of bronchopulmonary dysplasia chronic asthma definition effective 250mcg advair diskus, patent ductus arteriosus asthma symptoms for adults generic advair diskus 500 mcg overnight delivery, and subsequent development of cerebral palsy (Goryniak et al asthma with acute exacerbation generic advair diskus 250mcg online. The monitors do asthma definition 9 amendment 500 mcg advair diskus amex, however, provide reassurance to parents and physicians about the status of the infant. It normally closes at birth, allowing blood to flow to the lungs and be oxygenated. About 30% of premature infants, and more than 50% of those born weighing less than 1,000 grams, will have a patent (open) ductus arteriosus diagnosed during the first few days of life (Hamrick & Hansmann, 2010). This can lead to hypoxia, decreased blood flow to specific organs, and heart failure. If these measures fail, closure is possible using medications such as indomethacin or ibuprofen. In a small percentage of infants, surgical closure is required (Al Nemri, 2014; Noori, 2010). While from 2001 to 2008 the rate remained constant, it then declined to 40 deaths per 100,000 live births in 2013. The nutritional needs of the premature infant are also different from 74 Rais-Bahrami and Short those of the full-term infant and require the use of specialty formulas. Other predisposing factors include fetal distress, premature rupture of membranes, low Apgar scores, and exchange transfusion (where blood is gradually removed from the newborn and replaced with matched adult blood to treat Rh incompatibility). It results in chronic diarrhea, malabsorption, nutritional deficiencies, impaired growth, and the long-term need for intravenous nutrition (fats, carbohydrates, and amino acids provided intravenously through a central line). Treatment is targeted toward special positioning techniques and medications (see Chapter 10). The highest risk infants are those born at less than 28 weeks gestational age and weighing less than 1 kilogram at birth (Chan-Ling, Gole, Quinn, Adamson & Darlow, 2017). Follow-up examinations should be done until retinal vascularization is complete, usually around term gestation (see Chapter 7). As a result, the infant is at increased risk for infection in the first months of life (Wiliska, Warakomska, Gluszczak-Idziakowska, & Jackowska, 2016). Generalized bacterial and fungal infections, occurring in approximately 30% of extremely premature infants, are major life-threatening illnesses and can lead to a poor neurodevelopmental outcome (Wiliska et al. Premature infants who remain in the hospital for prolonged periods should receive routine immunizations based on their chronological age. Other Physiologic Impairments Premature infants are at increased risk for many of the same transient physiological impairments that occur in full-term infants. These include hyperbilirubinemia, anemia, hypoglycemia, hyperglycemia, hypocalcemia, and hypothermia. In kernicterus, there is the deposition of bilirubin pigment in the brain, leading to athetoid cerebral palsy, hearing loss, vision problems, and/or intellectual disability. Thus, the bilirubin level that is used to determine whether phototherapy or an exchange transfusion should be performed is lower for the preterm infant than for the full-term infant (Maisels, Watchko, Bhutani, & Stevenson, 2012). These infants develop anemia of prematurity due to inadequate production of erythropoietin, which normally stimulates the bone marrow to produce red blood cells. In severe cases, anemia of prematurity is corrected with blood transfusion and/or treatment with erythropoietin (Bishara & Ohls, 2009). Finally, premature infants often have a transient deficiency of thyroid hormone production. In severe cases, this condition may be associated with neurodevelopmental impairments. However, in most cases, the hypothyroidism resolves without the need for thyroid hormone replacement therapy and does not negatively impact long-term outcomes (van Wassenaer-Leemhuis et al. This starts with identifying women at risk and providing them with education and prenatal health care. In addition, detecting preterm labor early and using labor-arresting agents and antenatal steroid therapy are very effective methods for preventing neonatal mortality and morbidity (Roberts et al. Prenatal care has improved appreciably since the 1970s, but the incidence of preterm delivery remains high. The increased survival rate of preterm infants has the potential for increasing the number of children with adverse neurodevelopmental outcome. A variety of perinatal and neonatal factors have been associated with this improved outcome, including increased antenatal steroid use and cesarean section delivery. These interventions have resulted in decreased risk of sepsis and less severe cranial ultrasound abnormalities. There has, however been no change in the rate of chronic lung disease despite the postnatal use of steroids to stimulate surfactant production (Pierrat et al. A newer approach uses a more relationship-based, individualized, developmentally supportive model. This involves documenting infant behavior, including breathing pattern, color fluctuations, startles, posture, and sleep state. Caregiving suggestions and environmental modifications are then based on these observations. Research is ongoing to determine whether this approach carries long-term benefits. Once the infant is medically stable, a team consisting of a physical and/or occupational therapist, speech pathologist, developmental psychologist, and/ or developmental pediatrician should evaluate the child. Care plans should be developed to provide parents with training regarding the ongoing developmental needs of the child after discharge (see Box 5. This may also include referral to an early intervention program in the community (see Chapter 31). Although the overall survival for infants with a birth weight of less than 500 grams was only 8%, those who lived through the first 3 days of life had up to a 50% chance of survival. Infants in the 500- to 749-gram birth weight category had an overall survival rate of 50%. That increased to 70% if they survived through the third day and 80% by the end of the first week of life (Mohamed, Nada, & Aly, 2010). Neurodevelopmental impairment among surviving infants also declined from 68% to 47% (Younge et al. As a result, many centers are developing care pathways that allow the medical team to consider earlier discharge than previously practiced for stable premature infants. This new approach needs to be monitored closely to ensure that earlier discharge does not compromise the health of infants and result in an increased risk of readmission to the hospital for treatment of medical complications. When premature infants are discharged, parents may be faced with the stress and difficulty of caring for an infant with many special needs. Because of an immature sucking pattern, they often require more frequent feedings. Specialized formula and/or breast milk supplementation with a human milk fortifier are now available to meet the caloric needs of premature infants post discharge. As a result of these stresses, it is important to provide adequate support for the family after discharge, including close medical supervision and home- care visits by nursing and/or social work staff (Aydon, Hauck, Murdoch, Siu, & Sharp, 2017). Parental education regarding the needs of a growing preterm infant is extremely important. Ideally, the infant should be discharged to a home environment that is free of smoke and any other potential respiratory irritants such as kerosene heaters, fresh paint, and people with respiratory-related viral illness. Each of these factors plays a crucial role in causing subsequent respiratory illnesses or in exacerbating the underlying lung disease. The parents also learn about the care of their infant, thereby reducing the stress and anxiety of taking a preterm infant home (Broedsgaard & Wagner, 2005). With respect to motor outcomes, there were no differences between the groups receiving services and those not receiving services (Nordhov et al. These programs should start for many premature infants prior to discharge from the hospital and continue until the child reaches 3 years corrected age. It is important to recognize that even after completion of the early intervention program, many of these children continue to need special education services, including speech-language therapy, physical and/or occupational therapy, special education, behavior therapy, and treatment of emotional problems. If these children do not receive these services, the benefits of early intervention may be lost over time (Guralnick, 2012). There are, however, differences between full-term and preterm infants even when gestational age is taken into account. Although few premature infants develop cerebral palsy, in terms of motor skills, they often lack the smooth, rhythmic movement patterns of full-term infants. Devices such as walkers and jumpers should be avoided because they encourage the infant to stand on tiptoe and walk in an atypical pattern. In later infancy, visual-motor tasks that require the planned use of arms and hands are also more difficult. In a study of children with birth weights less than 2 kilograms, there was no 78 Rais-Bahrami and Short spoon, managing a standard cup, copying block constructions, and completing crayon/paper tasks can be more difficult (Sripada et al. By school age, the developmental status of preterm children who had birth weights above 1,500 grams is not very different from full-term infants. In terms of behavior issues, children born prematurely are at risk for lower levels of social competence, and they are often less adaptable, less regular in their habits, less persistent, and more withdrawn. In addition, there may be behavior differences such as sleep disturbances, feeding difficulties, tantrums, and/or resistance to limit setting (Johnson et al. Family factors have also been found to be strong predictors of future school performance (Garfield et al. Optimal school outcome has been significantly associated with increased parental education, child rearing by two parents, stability in family composition, socioeconomic status, and geographic residence. Major developmental disabilities have been found in about one quarter of children with a birth weight less than 1,000 grams. In one study, sensorineural hearing impairments were correlated with neonatal sepsis and jaundice; neurological, developmental, neurosensory, and functional morbidities increased with a decreasing birth weight; and, overall, males were more at risk for disabilities than were females. However, this lower capacity is not considered sufficiently severe to affect their educational level or social adjustment (Yi, Yi, & Hwang, 2016). Early and late complications of germinal matrixintraventricular haemorrhage in the preterm infant: What is new Use of physical and neurologic observations in assessment of gestational age in low-birth-weight infants. Brain development, intelligence and cognitive outcome in children born small for gestational age. Attention problems of very preterm children compared with age-matched term controls at school-age. Neuro-cognitive performance of very preterm or very low birth weight adults at 26 years. Usefulness of the Infant Driven Scale in the early identification of preterm infants at risk for delayed oral feeding independency. Preventive interventions for preterm children: Effectiveness and developmental mechanisms. Long-term cognition, achievement, socioemotional, and behavioral development of healthy late-preterm infants. Association between perinatal hypoxic-ischemia and periventricular leukomalacia in preterm infants: A systematic review and meta-analysis. Perinatal endocrinology: Common endocrine disorders in the sick and premature newborn. Early emergence of delayed social competence in infants born late and moderately preterm. Year 2000 position statement: Principles and guidelines for early hearing detection and intervention programs. Bronchopulmonary dysplasia in very and extremely low birth weight infants: Analysis of selected risk factors. A neurobehavioral intervention and assessment program in very low birth weight infants: Outcome at 24 months. Screening and treatment of maternal genitourinary tract infections in early pregnancy to prevent preterm birth in rural Sylhet, Bangladesh: a cluster randomized trial. An approach to the management of hyperbilirubinemia in the preterm infant less than 35 weeks of gestation. Motor development, infantile reactions and postural responses of preterm, at-risk infants. School-age effects of the newborn individualized developmental care and assessment program for preterm infants with intrauterine growth restriction: Preliminary findings. The diagnosis, management and postnatal prevention of intraventricular hemorrhage in the preterm neonate. Small-for-gestational-age infants among uncomplicated pregnancies at term: A secondary analysis of 9 Maternal-Fetal Medicine Units Network studies.
This damage might explain the high incidence of excessive salivation asthma nursing care plan generic advair diskus 500mcg visa, swallowing problems asthma or anxiety order genuine advair diskus online, strabismus asthma uptodate advair diskus 500mcg low price, and speech disorders in these children (see Chapter 21) asthma recurrent bronchitis cheap advair diskus 250mcg online. The importance of the cerebellum is increasingly being recognized for its contributions to coordination of voluntary motor activity asthma scientific definition advair diskus 500mcg fast delivery, cognition, emotion, language, and learning. During the late fetal and early postnatal period, the cerebellum undergoes unparalleled rapid growth and development (Brossard-Racine & Limperopoulos, 2016). It helps coordinate voluntary motor activity by dampening skeletal muscular activity. This enables a smooth transition between activating agonist muscles (that work together) and inhibiting their counterpart antagonist muscles. Normal muscle coordination requires that cerebellar functions be integrated with those of the cerebral hemispheres and the basal ganglia. Although voluntary movement can occur without the cerebellum, such movements are ataxic (erratic and uncoordinated). An ataxic gait may be seen with cerebellar tumors, progressive neurological disorders. Advanced imaging studies have revealed corticalcerebellar connectivity during cognitive testing of memory and executive function (Koziol et al. Furthermore, restingstate functional connectivity data demonstrate that the cerebellum is part of cognitive networks that include the prefrontal and parietal association cortices (Koziol et al. The clinical cerebellar cognitive affective syndrome, occurring in patients with cerebellar lesions, provides further evidence of cerebellar involvement in cognitive functions. The syndrome causes deficits in spatial processing, working memory, language, and emotional labiality (Hoche, Guell, Vangel, Sherman, & Schmahmann, 2017). A number of theories have been proposed regarding the specific contributions that the cerebellum makes to neural processes, including timing, sequencing, and learning associative relationships among elements (Baumann et al. This suggests that the cerebellum is important for extracting relevant information from the Brainstem In contrast to the cerebral hemispheres, which control voluntary actions, the brainstem controls more reflexive and involuntary activities. Within it are the cranial nerves that control functions such as vision, hearing, swallowing, and articulation. These cranial nerves also affect facial expression, eye and tongue movement, salivation, and even breathing. In addition to the cranial nerve nuclei, the brainstem is composed of a vast array of fiber tracts relaying messages into and out of the brain. The corticospinal tract provides a passage of neural impulses from the cortex to the spinal cord. Conversely there are tracts that bring sensory information to the cortex via the thalamus. Thus, the right hemisphere controls left-side movement, and the left hemisphere controls right-side movement. These findings support the theory that the cerebellum is crucial to the formation of internal models, which may apply to both movement and cognitive functions. The Spinal Cord the spinal cord transmits motor and sensory messages between the brain and the rest of the body. In addition to permitting voluntary movement, the spinal cord acts to provide protective reflex arcs in both the upper and lower extremities, such as the deep tendon reflex elicited when the knee is tapped. These enlargements correspond to the origins of the nerves of the upper and lower extremities. The nerves of the brachial plexus originate at the cervical (neck) enlargement of the spinal cord and control arm movement; the nerves of the lumbosacral plexus arise from the lumbar (lower back) enlargement of the spinal cord and control leg movement. Many patients with birth-related brachial plexus injuries recover enough motion and strength and do not need early surgery, but they do greatly benefit from occupational therapy. The spinal cord is divided into approximately 30 segments-8 cervical, 12 thoracic (chest), 5 lumbar, 5 sacral (pelvic), and a few small coccygeal (tailbone) segments-that correspond to attachments of groups of nerve roots. They are about twice as long in the midthoracic region as in the cervical or upper lumbar area. Each segment contributes four roots: a ventral (front) and dorsal (back) root arising from the left half and a similar pair of roots arising from the right half of the cord. The dorsal nerve roots allow sensory input to ascend to the brainstem, whereas the ventral roots deliver motor input from the brainstem to the appropriate muscle. The result is a loss (either partial or complete) of sensation and movement in the affected limbs. The paralysis, which is initially flaccid (hypotonic) but ultimately becomes spastic (hypertonic), may involve the legs (paraplegia) or all four extremities (quadriplegia) depending on the level of damage. The enlargement to the right shows a section of the cord taken from the upper back region. Note the meninges (the dura, arachnoid, and pia mater) surrounding the cord and the peripheral nerve on its way to a muscle. The gray matter consists of various nerve cells, the most important of which are the anterior horn cells. The white matter contains nerve fibers wrapped in myelin, which gives the cord its glistening appearance. Normal magnetic resonance imaging scan (left) and computed tomography scan showing hydrocephalus (right). In the image to the right, note the rounded appearance of the frontal horns (top) as well as the differentially enlarged occipital horns (bottom). This is known as culpocephaly and is frequently seen in individuals with spina bifida. The fluid is produced by the choroid plexus in the roof of the lateral and third ventricles. Its primary route is through the aqueduct of Sylvius, into the fourth ventricle, and then into the spinal column, where it is absorbed. This usually congenital condition involves an abnormal accumulation of fluid in the cerebral ventricles, causing skull enlargement in the infant and brain compression. In contrast, a communicating hydrocephalus is caused by a malfunction at the level of the arachnoid granulations. When fluid builds up inside the skull of an infant, the sutures (the joints connecting the bones of the skull) expand and dissipate the increased pressure at the expense of an increase in head circumference. This buildup of fluid can be life-threatening at any age and is considered a medical emergency. The complication rate for this surgery is low, and the long-term outcome is reasonably good. Once in place, however, numerous obstacles remain in maintaining a working shunt and avoiding infection. Many children require shunt revisions as a result of infection or because obstructions develop within the shunt. Managing hydrocephalus, however, has been simplified and often allows for a near-typical lifestyle. Endoscopic third ventriculostomy has the benefit of avoiding implants but is not feasible in all individuals with hydrocephalus (Lam, Harris, Rocque, & Ham, 2014). These nerves can have both motor and sensory fibers that run in opposite directions. Motor, or efferent, fibers transmit impulses from the brain to initiate movement, whereas sensory, or afferent, fibers carry signals from muscles, skin, and joints back to the brain. Sensory fibers convey information related to the position of a joint or the tone of a muscle following movement. Hyperexcitability of sensory neurons in the child with cerebral palsy contributes to spasticity. There are also a number of hereditary neuropathies that interfere with the peripheral nervous system (Stojkovic, 2016). This ability to promote the regrowth of peripheral nerves is responsible for the success seen in surgical reconstruction for brachial plexus palsy sustained during vaginal delivery. The brachial plexus is a network of nerves that conducts signals from the spine to the shoulder, arm, and hand. Symptoms include a limp or paralyzed arm; lack of muscle control in the arm, hand, or wrist; and a lack of feeling or sensation in the arm or hand. Complex coordination between the motor and sensory system is necessary to ensure normal muscle tone. Involuntary activities of the cardiovascular, digestive, endocrine, urinary, respiratory, and reproductive systems are controlled by the autonomic nervous system. In contrast to the graded response of voluntary movements, the autonomic nervous system involves an on/off type of control. When a person feels threatened, physically or psychologically, several physiological changes take place simultaneously. Digestive system functions are suspended so that blood can be diverted to more important areas for actions involved in fight or flight, such as the brain and heart. Heart rate and blood pressure increase, and the air passages of the lungs expand in size. Although the autonomic nervous system works involuntarily in maintaining homeostasis (metabolic equilibrium of the body), voluntary adjustments come from the cerebral cortex to modulate these effects. In an infant, when the bladder or rectum fills, the outlet muscles release automatically and the infant urinates or defecates with no conscious control. Between the ages of 12 and 18 months, however, the child starts to be able to gain control over these functions. The cerebral cortex begins to send inhibitory signals to reduce the normal autonomic activity. As any parent knows only too well, this coordination requires months (or years) of fine-tuning to master consistent control. These nerves control such involuntary motor activities as breathing, heart rate, and digestion. The Brain and Nervous System 129 are less able to inhibit the autonomic nervous system in this way. This explains the great difficulty that children with cerebral palsy, myelomeningocele, or traumatic brain injury may have in controlling bowel and bladder function. The axon carries impulses away from the nerve cell body, sometimes for a distance greater than a meter. Dendrites receive impulses from other neurons and carry them a short distance toward the cell body. The size and shape of dendrites may change with neuronal activity, suggesting that these changes may represent the anatomical basis for memory. Most of the neural progenitor cells that eventually mature into postmitotic neurons are produced in the ventricular zone. They migrate radially to form the six-layered neocortex-with the sixth layer being formed first and the more superficial layers formed later by migrating cells (Lui et al. Once the neurons have migrated to their target region, they grow in size, differentiate, and develop neuronal processes. The major developmental features of this organizational period include 1) the establishment and differentiation of neurons; 2) the attainment of proper alignment, orientation, and layering of cortical neurons; 3) the elaboration of dendrites and axons; 4) the establishment of synaptic contacts; and 5) cell death and selective elimination of neuronal processes and synapses. As the neurons develop, the growing axons are able to recognize various signaling molecules that are on the surface of other axons and cell bodies. Based on these signaling cues, the axons move forward (sometimes rapidly), avoid obstacles, and stop when their target is reached. These guidance functions-sensory, motor, and integrative-are contained within the specialized tip of a growing axon, the growth cone (Tamariz & Varela-Echavarria, 2015). The spines increase the surface area of the dendrites, permitting more elaborate communication between the neurons. In fact, increased dendritic outgrowth has been associated with enhanced memory, and deficient development of dendritic arborization has been observed in individuals with cognitive impairment, most notably in Down syndrome (Huttenlocher, 1991). The enlargements show the minute dendritic spines that increase the number of synapses or junctures among nerve cells. Note the diminished size and number of dendritic spines in a child with Down syndrome. Neurotransmitter bundles are released into the cleft from vesicles in the presynaptic membrane. Synapses can be either chemical or electrical, with distinct characteristics for each type. In electrical synapses, there is a short distance between the two neurons, and there is a communication between the cytoplasm of the cells. Because of this, there is very little delay as an electric current passes from one neuron to the next, and the transmission is usually bidirectional. In contrast, chemical synapses have a larger gap between the two neurons and no direct communication of the cytoplasm. Small vesicles (fluid-filled sacs within cells) containing specific neurotransmitters are released from the axon of one neuron and travel the distance between the cells to reach the receptors for that particular neurotransmitter on the dendrite of the second neuron. The effect on the postsynaptic cell can be either excitatory or inhibitory depending on the neurotransmitter and the cell type. Within a network of cells, electrical and chemical synapses work together to foster synchrony. During early stages of brain development, there are initially an excess number of connections. This exuberant number of synapses throughout the brain gradually declines beginning during the early postnatal period and continuing throughout childhood and adolescence. The purpose of this process is to remove redundancy and enhance connectivity between pertinent neural networks.
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