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The Federal Register also recognizes the roles and potential limitations of various other pro fessionals who may work with children with disabilities: There are many professionals who might also play a role in developing and delivering positive behavioral intervention strategies. The standards for personnel who assist in developing and delivering positive behavioral intervention strategies will vary depend ing on the requirements of the State. Including the development and delivery of pos itive behavioral intervention strategies in the defnition of psychological services is not intended to imply that school psychologists are automatically qualifed to perform these duties or to prohibit other qualifed personnel from providing these services, consistent with State requirements. In addition, mental health practitioners who are providing play therapy should have had specialized training in this modal ity. Even with these specialty credentials, the play therapist needs to seek continuing education, and when working with a disability with which the play therapist is unfamiliar, the therapist should seek consultation or supervision from a more experienced play therapist. Therapist Characteristics Specifc characteristics of play therapists who have been successful in working with children with disabilities could not be determined from the literature search. The British nuture teachers are trained special education teachers who work with children with social, emotional, and behavioral diff culties. Beyond formal training, certain personal characteristics may make an educator, mental health worker, or medical personnel better suited to work with children with disabilities. Syrnyk (2012) found that nurture teachers in the British education system were described as having an inner strength, a calm empathetic nature, self-awareness, and objectivity. Nurture teachers were found to value tenacity, but could meet the demands of high-pressure situations while maintain ing a relaxed and reasoned demeanor. Logically, these characteris tics would be desirable in play therapists who wish to positively infuence the growth of children with disabilities. In summary, those who will be providing play therapy to children with disabilities need four things. First, they need to be well educated with respect to the diagnosis and conceptualization of disability. Second, they need to be well informed regarding the laws, guidelines, and ethics governing services to children with disabilities. Third, they need to be well trained in the feld of Pthomegroup Play Therapy With Children With Disabilities 407 play therapy in general and its application to work with children with disabilities. Finally, play therapists, like the nurture teachers, need personality attributes that include being able to provide a calm, accepting environment in which the child can experience success. Client Characteristics Children with disabilities represent a broad and greatly varying population with divergent limita tions and strengths. The severity of the dis ability and the level of interaction present a challenge to the play therapist. While play therapy has been used with most of the types of disabilities that children may face, modifcations have had to be used in many cases to accommodate the special needs of the child. Indications/Contraindications Play therapy has been used and found to be effectiveaseitheraprimaryorasanadjunctinterven tion to address a broad range of behavioral, emotional, and social issues experienced by children with and without disabilities (Carmichael, 2006; Gil, 2010; Landreth, 2005). In addition to con cerns related to the disability, such as pain, grief, and hospitalization, these children often have to cope with everyday stresses such as those related to divorce, relocation, abuse, domestic vio lence, and natural disasters, all of which have responded to play therapy interventions (Reddy, Files-Hall & Schaefer, 2005). Landreth (2012) suggests child-centered play therapy may be con traindicated for children who may not be able to establish a therapeutic relationship, such as those with severe autism spectrum disorders or those with schizophrenia. However, other, more structured forms of play therapy may be suited for work with these children. Adapting the Play Room Depending on the disabilities of the children being treated, the therapist may need to signifcantly modify the playroom.

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Depending upon the mode of pathogenesis, the spectrum However, most pathogens were detected by histopathology of causative agents will vary (Table 13). Acanthamoeba sp (n = 8) sis of endophthalmitis can be obtained by aspiration of aqueous Table 13. The other bacteria listed may cause endophthalmitis either secondary to trauma or surgery or following hematogenous seeding. Both the slant and the smear (if prepared) should be transported directly to the laboratory for further processing. The other fungi listed typically cause infection following traumatic inoculation of the eye. Alternatively, vitrectomy, a surgi pathognomonic for toxoplasmosis, demonstrating retinocho cal procedure, allows collections of comparatively large fluid vol roiditis in a majority of cases. Because the specimen gram-positive organisms with coagulase-negative staphylococci needed for testing can only be obtained by an experienced oph predominating; chronic postoperative endophthalmitis can be thalmologist and is an invasive procedure, it is unlikely that this due to C. Postcorneal endophthalmitis of blood, vitreous, or aqueous fuids is not as sensitive as intra is due primarily to Candida spp (65%) and gram-positive organ ocular antibody determinations, but the specimens for testing isms (33%), with Candida and the majority of the gram-positive may be more easily obtained. Finally, metagenomics analysis is beginning to be applied in Toxoplasma gondii is the most common infectious cause of research settings for the diagnosis of unusual cases of uveitis. Diagnosis is typically made on clinical grounds sup diagnostic approach is likely to be available for the diagnosis of ported by serology. In the industrialized world, the presence of endophthalmitis, uveitis, and retinitis in the near future [76]. Infection of various spaces and tissues that occur in the head Key points for the laboratory diagnosis of head and neck sof and neck can be divided into those arising from odontogenic, tissue infections: oropharyngeal, or exogenous sources. These infections include peritonsillar and pharyngeal Submit tissue, fluid, or aspirate when possible. Accurate etiologic diagnosis depends upon odontogenic, oropharyngeal, and exogenous sources. The opti collection of an aspirate or biopsy of inflammatory material from mum approach to establishing an etiologic diagnosis of each affected tissues and tissue spaces while avoiding contamina condition is provided. The specimen should be placed into an anaerobic transport container to support the recovery of A. Infections of the Oral Cavity and Adjacent Spaces and Tissues Caused by Odontogenic and Oropharyngeal Flora (Table 14) anaerobic bacteria (both aerobic and facultative bacteria survive in anaerobic transport). Mastoiditis and Malignant Otitis Externa Caused by Oropharyngeal and standard for all anaerobic cultures because they allow the labo Exogenous Pathogens (Table 15) ratorian to evaluate the adequacy of the specimen by identify ing inflammatory cells, provide an early presumptive etiologic V. Additionally, spirochetes Infections in the upper respiratory tract usually involve the ears, (often involved in odontogenic infection) cannot be recovered in the mucus membranes lining the nose and throat above the epi routine anaerobic cultures but will be seen in the stained smear. Inappropriate utilization of antibiotics for viral infections is a parotitis [77, 83]. Because the epiglottis may swell dramatically major driver of increasing antibiotic resistance. Proper diagnosis of during epiglottitis, there is a chance of sudden occlusion of the infectious syndromes in this environment must involve laboratory trachea if the epiglottis is disturbed, such as by an attempt to col tests to determine the etiology and thus inform the proper therapy. Blood cultures are the preferred sample for Key points for the laboratory diagnosis of upper respiratory the diagnosis of epiglottitis; if swabbing is attempted, it should tract infections: be in a setting with available appropriate emergency response.

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Children with autism often do best when assessed with tests that require less social engagement and less verbal mediation. In addition to the formal quantitative information pro vided, a comprehensive psychological assessment will also provide a con siderable amount of important qualitative information (Sparrow, 1997). It is important that the psychologist be aware of the uses and limitations of standardized assessment procedures and the difficulties that children with autism often have in complying with verbal instructions and social rein forcement. Difficulties in communication are a central feature of autism, and they interact in complex ways with social deficits and restricted patterns of behavior and interests in a given individual. The selection of appropriate assess ment instruments, combined with a general understanding of autism, can provide important information for purposes of both diagnostic assess ment and intervention. In addition to assessing expressive language, it is very important to obtain an accurate assessment of language comprehension. In children with au tism, the range of communicative intents may be restricted in multiple respects (Wetherby et al. Delayed and immediate echolalia are both common in autism (Fay, 1973; Prizant and Duchan, 1981) and may have important functions. In addition, various studies have documented unusual aspects even of very early communication development in au tism (Ricks and Wing, 1975; Tager-Flusberg et al. In assessing language and communication skills, parent interviews and checklists may be used, and specific assessment instruments for chil dren with autistic spectrum disorders have been developed (Sparrow, 1997). For children under age 3, scores on standardized tests may be particularly affected by difficulties in assessment and by the need to rely on parent reports and checklists. There are also several standardized instruments that provide useful information on the communication and language de velopment of preverbal children with autism; these include the Commu nication and Symbolic Behavior Scales, the Mullen Scales of Early Learn ing, and the MacArthur Communicative Development Inventory. For children with some verbal ability, social and play behaviors are still im portant in terms of clinical observation but various standardized instru ments are available as well, particularly when a child exhibits multiword utterances. Areas to be assessed include receptive and expressive vo cabulary, expressive language and comprehension, syntax, semantic rela tions, morphology, pragmatics, articulation, and prosody. The choice of specific instruments for language-communication as sessment will depend on the developmental levels and chronological age of the child. As with other aspects of assessment, an evalua tor should be flexible and knowledgeable about the particular concerns related to assessment of children with autism. Motor abilities in autism may, at least in the first years of life, repre sent an area of relative strength for a child, but as time goes on, the development of motor skills in both the gross and fine motor areas may be compromised, and motor problems are frequently seen in young chil dren with autism. Evaluations by occupational and physical therapists are often needed to document areas of need and in the development of an intervention program (Jones and Prior, 1985; Hughes, 1996). Standard ized tests of fine and gross motor development and a qualitative assess ment of other aspects of sensory and motor development, performed by a professional in motor development, may be helpful in educational plan ning. The education of physicians, nurses, and others regarding warning signs for autistic spectrum disorders is very important. After initial referral for assessment and diagnosis, consultations with other medical professionals may be indicated, depending on the context (Filipek et al. When this consulta tion is relevant to the educational program, reimbursement may appro priately be made by the local education authority. The available literature has clearly documented that children with autism are at risk for developing seizure disorders throughout the devel opmental period (Deykin and MacMahon, 1979; Volkmar and Nelson, 1990). Seizure disorders in autism are of various types and may some times present in unusual ways.

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Siegel (2006) demarcated late adolescence as the time when an individual typically learns to integrate and resolve states that cause conficts within the organism. The mirror neuron system is also a vital contributor of brain development (Levy, 2009). The limbic system and cortical structures continue to develop across the life span; how ever, the fastest rate of development occurs within the frst three years of life. During the frst year, the size of the cerebellum near triples, allowing the infant to develop motor skills quickly (Knickmeyer et al. The third year is marked by increased synaptic density in the prefrontal cortex and the continued formation and consolidation of the neural connections to other areas of the brain. Pthomegroup Neuroscience and Play Therapy: the Neurobiologically-Informed Play Therapist 587 Beyond relationships, play is also a critical aspect of early childhood brain development. The holistic nature of play promotes the integration of the cortical and subcortical processes, provid ing an environment for sustained emotional change (Panksepp, 2003) and increased empathic abilities (Siegel, 2006). While describing brain development, it is necessary to briefy mention neurotransmitters. Human existence and functioning can be described as a complex system of electrical impulses, neurochemicals, and neuromodulators. The three elements are inseparable, likely of equal impor tance, and necessary for survival. For the purposes of this chapter, neurotransmitters are of utmost importance, specifcally those involved in the regulation of emotion and disruptive behaviors. As a means to understanding commonalities rather than individual disorder differences, Hudspeth (2013) described disruptive behavioral symptoms common across diagnoses from the perspective of neurotransmitter system involvement. He states: I will categorize disruptive behaviors based on neurotransmitters and brain regions. Without proper functioning of these neurotransmitter systems, an individual is dysregulated and dysfunctional. Later in the chapter, these neurotransmitters will be discussed in terms of how they are infuenced by medications. Emotional Development Franks (2006) suggests it is best to conceptualize the emotional brain rather than specifc regions within the brain dedicated to emotions. Whether we are discussing the processes that generate emotions or the processes that allow an individual to feel emotions, different regions of the brain are activated (Berridge & Kringelbach, 2013). Together, this has moved research from focusing on dedicated emotional regions, such as the limbic system, toward trying to understand the complex interplay of cortical and subcortical systems. In addition, the environment plays a role in the emotional stimuli we experience, how we feel and interpret emotional stimuli, and how that felt experience is fed back into higher cortical structures and/or stored as memories (Goldsmith et al. Keeping the above in mind, while reading the next sections discussing specifc brain regions, it becomes clear there is a great deal more to learn about emotions and the brain. These emotional experiences also include how they interact with their caregivers by conveying their felt emotions and interpreting the emotions of others.

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