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However, in autistic spectrum disorders, the intensity, frequency, duration, or persis tence of the behaviors distinguish them from similar behaviors of nor mally developing young children. For example, several studies have shown that self-injurious and stereotyped behaviors occur in normal in fants and then decrease, although they do not necessarily disappear, as locomotion develops in these children during the first and second years of life (Thelen, 1979; Werry et al. Body-rocking occurred in 19 percent and head-banging in 5 percent of one sample of typical children ages 3 to 6 years (Sallustro and Atwell, 1978). Similar levels of body rocking have also been reported in normal college students (Berkson et al. These repetitive movements and potentially self-injurious behaviors are presumed to serve some function in normal development (Berkson and Tupa, 2000). Berkson and Tupa (2000) found that about 5 percent of toddlers with developmental disabilities (including autistic spectrum dis orders) engaged in head-banging, about the same percentage as reported for typically developing children. The incidence of head-banging with actual injuries in the group with developmental disabilities is presumably greater: between 1. This rate is similar to the prevalence rates reported for older, non institutionalized populations of children and adults with developmental disabilities (Rojahn, 1986; Griffin et al. Understanding what causes these problem behaviors to emerge dur ing the early childhood and preschool years, what maintains them, and what evokes their moment-to-moment expression holds promise of treat ments to prevent them from becoming permanent and abnormal (Berkson and Tupa, 2000). Without appropriate intervention, these be haviors persist and worsen (Schroeder et al. With increasing research into the neurobiology and genetics of au tism, the organicity of some aspects of behavior in autism is becoming clearer. For example, Lewis (1996) has attempted to explicate some of the underlying neurobiology of repetitive or stereotyped behaviors. For example, some self injurious behaviors involve the release of neurochemi cal transmitters and modulators that subsequently bind to specific brain receptors. Epidemiological studies indicate that a substantial minority of all young children, with or without developmental disorders, exhibit prob lem behaviors at some time that might benefit from intervention (McDougal and Hiralall, 1998; Emerson, 1995). Young children with poor social skills or limited communication, including children with autistic spectrum disorders, are especially at risk for such problems (Borthwick Duffy, 1996; Koegel et al. An analysis of five reviews of interven tion approaches for the general population of individuals with develop mental disabilities, conducted between 1976 and 2000, found that the target behaviors most often addressed in intervention studies were ag gression, destruction of property, disruption of activities, self-injury, ste reotypic behavior, and inappropriate verbal behavior (Horner et al. However, there is an increas ing consensus among developmental, psychosocial, applied behavior, and legal experts that prevention of such problems should be a primary focus, particularly during the early childhood and preschool years (Berkson and Tupa, 2000; Schroeder at al. In short, before assessing deficiencies in a child who is misbehaving, it is critical to assess the adequacy of the intervention program the child is receiving. Comprehensive Treatment Programs Various comprehensive treatment programs encompass a number of different philosophical and theoretical positions, ranging from strict op erant discrimination learning (Lovaas, 1987) to broader applied behavior analysis programs (Harris et al. Comprehensive pro grams generally require 25 or more hours of active student engagement per week for 2 or more years and attempt to change the clinical course of an autistic spectrum disorder, including prevention of or reduction in problem behaviors. Applied Behavior Analysis Forty years of single-subject-design research testifies to the efficacy of time-limited, focused applied behavior analysis methods in reducing or eliminating specific problem behaviors and in teaching new skills to chil dren and adults with autism or other developmental disorders. Initially, applied behavior analysis procedures were reactive, focusing on conse quences of behaviors after they occurred, and interventions of this type continue to play an important role (see below). However, there has been increasing attention to intervention procedures that focus on what to do before or between bouts of problem behaviors (Carr et al. Since the mid-1980s, applied behavior analysis prevention strategies have focused on antecedent conditions in the child or the environment that set the stage for or trigger the problem behaviors (Carr et al. Interventions that involve changing schedules, modifying curricula, rearranging the physical setting, and changing social groupings have been shown to decrease the likelihood of problem behaviors (Carr et al. Many of these antecedent interventions have been implemented for years by some of the comprehensive, developmental programs described earlier (Mesibov et al.
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Daily application is inappropriate and may lead to systemic absorption of the medication. Application of mayonnaise to the hair is a treatment that has been recommended for head lice. Other itchy conditions, such as atopic dermatitis, rarely cause papules or nodules in this area. Conditions such as psoriasis and lichen planus can commonly affect the genitalia, but lesions are not typically nodular. Verrucous papules and nodules in the genital region may be a sign of sexual abuse. It is theorized that the organism cannot attach as easily to the oval hair shafts of kinky hair. Diffuse scaling in the setting of pustules and broken hairs is more suggestive of tinea capitis, and this infection is more common among African Americans. Round patches of frank alopecia are seen in alopecia areata, and this condition is not usually itchy. Diffuse greasy scale is typical of seborrheic dermatitis and more common in adolescents and adults. Decreased hair density with hairs of variable length are the findings of trichotillomania. The nonprescription cream rinse products are more effective when applied to dry hair and need to be left on the hair for several hours. Finally, removal of intact nits is critical because these represent the unhatched eggs. In some instances, old nits may simply represent the eggshell, without a live organism. Therefore, some patients with old nonviable nits will be barred from school, although they are in fact no longer infectious. It is thought that those nits closest to the scalp are most viable because of the necessary body temperature for hatching; however, this remains unproven and should not be relied on. Nits can be seen on hair shafts with the naked eye, but determination of the presence of an egg within requires microscopic examination. The skin lesions consist only of excoriations and areas of pinpoint bleeding representing sites of bites. Body lice most commonly affect the homeless and those with poor hygiene practices. It is believed to be transmitted by skin-to-skin contact; however, it is unclear whether fomites are a risk and how much of a role is played by swimming and bathing with affected individuals. The lesions are classically found clustered in warm, moist areas such as the axillae, groin, antecubital fossae, and popliteal fossae. Those with underlying skin disease such as atopic dermatitis have a higher risk of spreading the lesions because of a compromised skin barrier and baseline scratching. The lesions do tend to spontaneously resolve eventually, although the time course is variable from weeks to months to years. Alternative treatments include curettage, cryotherapy, and application of cantharidin or a similar destructive agent. Salicylic acid is useful in the treatment of warts; however, it likely will not be effective for this condition and will be irritating. A large percentage of childhood cases actually resolve spontaneously over months to years. Lesions are distinguished by the rough surface that disrupts skin markings and the presence of thrombosed capillaries, which account for the friability and bleeding that are often reported. Callus will always be in an area of friction and pressure and will not disrupt the skin lines or produce thrombosed capillaries.
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Logic models are provided in the research bulletins to clarify activities that theoretically contributed to the outcomes, and may be helpful in both replication and future research. Finally, it is important to note that the documentation of promising practices provided in this report is the first step in understanding policies and procedures that contribute to sexual assault prevention and intervention in jails and juvenile facilities. The strategies described here require further study to better understand if and how each practice contributes to facility safety. We introduce this for antisocial behavior that report with a brief overview of institutional sexual assault. Most of the research on rape in criminal justice facilities has been conducted in adult prisons. While the information on rapes in adult prisons is limited, even less is known about rapes in jails and juvenile facilities. It is likely that research conducted in prisons has some relevance to adult jails although it is unknown to what extent the prison research related to sexual assaults in juvenile facilities. The Prison Rape Elimination Act of 2003 was unanimously passed by both Houses of Congress and quickly signed by the President in September 2003. The Act explicitly describes the multitude of social, health and punishment problems that result from prison rape. Foremost among these is recurrence of violent, prison-learned behavior by both victims and perpetrators once they are back in the community. Violent attitudes and behaviors that take place after release from the institution present a significant public safety threat to the free community. Infected individuals eventually return to their homes in the free community, endangering the lives of intimates and damaging the efforts by public health organizations to contain these and other similarly contagious diseases. As stated in the Act, preventing prison rape protects taxpayer investments that have been made in health care, disease prevention and other initiatives designed to ensure the health and safety of inmates and individuals in the free community. In the meantime, the cost of health care and confinement are increasing, the size of prisoner and parole populations are increasing, and the size of state budgets to manage disease and other needs of citizens are decreasing. The problem of prison rape affects the safety and health of prisoners and staff inside the prison, and the safety and health of our communities outside the prison. The threat or occurrence of rape compromises the safety of both inmates and staff and, like other forms of institutional violence, contribute to a dangerous environment. French and Gendreau (2006) found that prison misconduct seems to reflect a propensity for antisocial behavior that cuts across social situations. Victims may engage in destructive behavior to psychological or physically escape from sexual assaults. Research conducted with sexual assault victims in the community indicates that victimization results in increased rates of substance abuse, suicide attempts, depression and post traumatic stress disorder (Kilpatrick, Edmunds, & Seymour, 1992). These issues can increase facility management problems destabilize the population. Research indicates that In addition, anecdotal information suggests public safety may be institutional sexual assault compromised when offenders and victims are released back into the perpetrators pose a community. Victims may be less stable emotionally, facilitating on-going significantly increased risk to criminal behavior in the community (Mariner, 2000). Perhaps most community safety upon release importantly, research indicates that institutional sexual assault perpetrators from prison (Heil, Harrison, pose a significantly increased risk to community safety upon release from English & Ahlmeyer, 2009). Past studies of prisoners have found that those with certain characteristics are most vulnerable to rape. The prison rape literature (Dumond, 2000, 1995, 1992; Heilpern, 1998; Cotton and Groth, 1982, 1984; Donaldson, 1993; Lockwood, 1978; Sacco, 1975, 1982) identifies the following groups as being particularly at risk: 1. Inmates who are young, inexperienced in prison culture, and easily intimidated; 2. Finally, it is important to note that this information is limited to the characteristics of individuals who were willing to report sexual victimization to researchers and may not include the characteristics of all inmates who are at risk to be sexually assaulted. Although less is known about perpetrators of prison sexual assaults, some frequent characteristics have been identified by researchers (Mariner, 2001; Nacci & Kane, 1982).
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Unless two treatments of equal potential value can be compared, such assignment creates the ethical issue of not providing the most promising treatment to children who might benefit. An argument is sometimes made (as it often is in medical treatment studies) that until a treatment is supported by a randomized clinical trial, the evidence for effectiveness of the treatment does not exist. In addition, when children are randomly assigned to two different treatment conditions, a researcher still must closely assess the experiences of the child and family, because families may seek and obtain services for their children outside of the treatment study. Ideally, chil dren and families could be assigned to equally attractive alternative treat ments, so that the research question changes from one of single treatment effectiveness to treatment comparison. Another issue related to random assignment is the heterogeneity of the population of children with autistic spectrum disorders. Most treat ment studies, because of the prevalence of autistic spectrum disorders and the expense and labor intensity of treatment, will have small sample sizes. Random assignment within a relatively small, heterogeneous sample does not ensure equivalent groups, so a researcher may match children on relevant characteristics. As noted above, such stratification of the sample of partici pants requires a thorough description of the participants as well as confi dence that the variable(s) on which children are matched are of greatest significance. An issue related to the size and heterogeneity of groups in the ran domized clinical trail approach is statistical power (Cohen, 1988). Groups have to be large enough to detect a significant difference in treatment outcomes when it occurs. The smaller the size of the group, the larger the difference in treatment outcomes has to be in order to show a statistically significant effect. Also, variability on pretest measures, as may occur with heterogeneous samples, sometimes obscures treatment differences if the sample size is not sufficiently large. Because the number of children with autistic spectrum disorders enrolled in particular treatment pro grams often is not large, sample size and within-group variability are challenges to the use of randomized clinical control methodology for determining the effectiveness of educational interventions for those children. Single-Subject Designs In contrast to group experimental designs, single-subject design meth odology uses a smaller number of subjects and establishes the causal relationship between treatment and outcomes by a series of intrasubject or intersubject replications of treatment effects (Kazdin, 1982). The two most frequently used methods are the withdrawal-of-treatment design and the multiple baseline design. When reliable changes in the outcome variable occur, the treatment is withdrawn in the third phase of the study, and concomitant changes in the outcome variable are examined. Often, the treatment is reinstated in a fourth phase of the study, with changes in the outcome variable expected. Data are collected for all participants in an initial baseline phase, and then the treatment is begun with one participant while the others remain in the baseline phase of the study. When changes occur for the first participant, the treatment is introduced for the second partici pant, and when changes occur for the second participant, the treatment is introduced for the third participant. Variations on this design include multiple baselines across behaviors of single individuals and multiple baselines across settings. Again, the researcher infers a functional rela tionship when changes reliably occur only after the treatment is imple mented across (usually three) participants, settings, or behaviors. Third, unlike group designs, in which the treat ments often represent a range of theoretical perspectives, treatments evaluated through single-subject designs tend to follow an applied be havior analysis theoretical orientation (Kazdin, 1982). There are methodological problems and limitations when single-sub ject designs are applied to studying children with autistic spectrum disor ders. The most obvious is that only a small number of children are in volved in any single study, so the applicability of findings of a single study to other children is limited. Single-subject designs build their exter nal validity on systematic replications across studies (Tawney and Gast, 1983). The issue of inter and intrasubject variability also exists for this meth odology. Such variability could contribute to the limitations of the external validity of a study. Two key issues in single-subject methodology relate to generalization and maintenance of treatment effects. In this context, generalization re fers to the occurrence of desired treatment outcomes outside of the treat ment settings and with individuals who were not involved in the treat ment. Maintenance refers to the continued performance of the behaviors or skills acquired in treatment after the treatment has ended.
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The diagnosis is typically made by the combination of physical examination and the appearance of clearly defined, homogeneous, hypoechoic densities on ultrasonography. Most fibroadenomas are less than 3 cm in diameter; giant fibroadenomas are more than 5 cm. Management is usually conservative, because many fibroadenomas will spontaneously regress. Giant fibroadenomas may necessitate surgical excision because of breast distortion. Breast abscesses typically present acutely, with symptoms of inflammation such as erythema, pain, swelling, and fever. Treatment should include coverage for likely skin pathogens (eg, staphylococci, streptococci). Breast cancer is uncommon among adolescents; therefore, both breast carcinoma and phyllodes tumor are unlikely in this scenario. Adolescents with fibrocystic changes in the breast often complain of breast tenderness, with peak symptoms near the time of menstruation. Management includes analgesics; symptoms typically improve with oral contraceptives. Physiologic gynecomastia occurs at puberty, and is likely due to a relative delay in testosterone secretion in comparison with estrogen, which stimulates breast development. She received early intervention services for delays in language, cognitive, and motor development until 3 years of age. Her parents are concerned about finding the best placement for their daughter in school. They are worried that she may not be able to keep up with her peers and want her to have as much support as possible. As such, she does not require specialized academic instruction for cognitive delay or a learning problem and does not require occupational therapy for fine motor problems. On the other hand, this child would benefit from speech therapy, as her speech is less than the 100% intelligibility expected for her age. She may also benefit from physical therapy or adaptive physical education to address her difficulty with ambulation. For the girl in this vignette, who does not require specialized academic instruction, the best recommendation would be a regular class for the majority of the day, with services for speech therapy and physical therapy or adaptive physical education for part of the day. Some states also provide services to children who are at high risk for developmental delays. Early intervention programs are multidisciplinary, community-based, and family-centered. Early intervention starts with identification, screening, and assessment to determine eligibility and needs. Services such as special instruction, speech therapy, occupational therapy, physical therapy, family training, and counseling are offered, based on the needs identified through the assessment process. Additional services include home visits and assistance with transitioning to community or special education services as appropriate. Early intervention has been most successful in children with mild delays and those at risk for developmental disability. If the child qualifies for special education services, an Individualized Education Program is developed, outlining the services and accommodations that will be provided to the child to meet his educational needs. This means that the child should be educated in typical educational settings with students without disabilities as much as possible. Although some children will require intensive services in a separate special education classroom or school, a child should receive support in a regular classroom with his typical peers, if feasible. Inclusion can teach students with and without disabilities about the diversity of their community and promotes tolerance, empathy, and collaboration among students. Included students with disabilities may show improvements in their communication and social skills, as well as better educational outcomes. General education teachers may feel inadequately prepared to provide optimal instruction to students with disabilities.