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Vice Chair, Touro College of Osteopathic Medicine

The father bullies the family into accepting his right to abuse the children allergy symptoms headache fever buy generic claritin 10mg online, so the abuse serves to regulate conflict within the family allergy medicine okay while breastfeeding buy 10 mg claritin overnight delivery. These families respond to the disclosure of abuse with less intensity than do overorganised families allergy medicine that is safe during pregnancy purchase claritin 10mg without prescription, and incorporate professionals into them like members of an extended family to help them manage their many problems allergy treatment laser purchase claritin 10mg with mastercard, which often include social disadvantage, educational difficulties, physical child abuse, neglect and marital discord. This problem of conflict by proxy will be discussed in a later section (Furniss, 1991). Overorganised families apparently function in an ideal fashion, with an idealised marriage and apparently adequate child care. The father typically abuses a single child, and this is kept secret and remains unacknowledged within the family. Sexual dissatisfaction within the marital relationship, conflict avoidance within the marriage, and a non-supportive relationship between the abused child and the mother characterise these families. The father and daughter may take on parental roles with respect to the ill mother, or the father may take on the role of the bully to whom both his partner and daughter are subordinate. In other instances, sexual dissatisfaction within the marriage may be associated with the father viewing himself as subordinate to his partner. In these cases, the father and daughter may both adopt child-like roles with respect to the mother. Following disclosure, mothers in these families may immediately file for divorce and fathers attempt suicide because of the discrepancy between the reality and the idealised family image. In both overorganised and underorganised families, a central risk factor is the absence of a supportive and protective relationship between the non-abusing parent and the child. With intrafamilial sexual abuse where the non-abusing parent offers the child support, and for extrafamilial abuse where both parents offer the child support, these relationships are protective factors. Secure parent-child attachment, and authoritative parenting within the context of a flexibly organised family in which there is clear communication, create a protective context for youngsters who have been sexually abused by someone outside the family. With intrafamilial abuse, a central protective factor is the insistence by the nonabusing parent that the abusing parent leaves the home, engages in treatment, and has no unsupervised contact with the child. Social contexts in which the child and abuser are relatively isolated create opportunities for abuse and reabuse, and so isolation is an important risk factor. In contrast, children who are offered high levels of support tend to show better adjustment. Where there is a lack of co-ordination among involved professionals or unresolved disagreements about whether the case warrants a diagnosis of sexual abuse, this increases the risk of further abuse. Factors associated with child-protection processes, including a lack of support at disclosure, multiple investigative interviews, multiplacement experiences, extended legal proceedings, and proceedings which are not child centred or child friendly, all contribute to the amount of stress experienced by the child. Families are more likely to benefit from treatment when all family members accept that there is a problem and the parents accept responsibility for the emotional abuse or neglect. Different courses of action will be required depending upon the relationship of the child to the alleged abuser and the level of suspicion that abuse has occurred. The only complicating factor in these cases is where both of the parents have a particularly close relationship with the alleged abuser and are likely to disbelieve the child. In these cases and in cases of sibling abuse, however, it is often possible to arrange for parents to put protective measures in place to prevent further abuse without their fully accepting the reality of the abuse, since the alternative may be for the child to be placed in care. Dealing with disbelief may then be a focus for subsequent family-based intervention. It is useful in these cases to draw a distinction between vague, first-line suspicions and well-founded and well-documented, second-line suspicions (Furniss, 1991). With vague, first-line suspicions, little information on the factors listed in Figure 21. A problem with arranging a full assessment without considerable forethought and planning is that if sufficient information cannot be gathered to determine whether or not abuse occurred, the child may return to a situation in which she is intimidated into retracting her statement. So, with first-line suspicions the main course of action is to convene a meeting of all involved professionals to pool information and plan further information-gathering strategies, such as a review of contacts with the family doctor or a behaviour-monitoring programme at school. It is vital that a case co-ordinator be appointed to take responsibility for directing this process of information gathering and arranging periodic reviews with the professional network to determine if the vague, first-line suspicion has developed into a clear and well-documented, second-line suspicion. In jurisdictions where there is mandatory reporting of all cases of suspected child abuse, such a report must be made at this early stage unless there is a stipulation in the mandatory reporting policy about the amount of supporting evidence that must be available before reporting suspected child sexual abuse.

Schools allergy forecast cincinnati 10 mg claritin, if they are to be maximally supportive of traumatised youngsters lidocaine allergy purchase claritin 10mg with amex, require psychoeducational input allergy treatment tree pollen order claritin 10mg mastercard. Where one child in a school has been traumatised allergy shots cancer generic 10mg claritin otc, it is maximally beneficial if a three-way meeting between the child and family, the school and the psychologist is arranged to provide this input. In the school meeting, the profound effects of intrusive memories and feelings on concentration and academic performance should be highlighted. Arrangements should also be made for youngsters to have a special teacher to whom they can go if they become particularly distressed during school hours. The special teacher should be briefed on how to facilitate the child in expressing concerns, and informed that ventilating feelings and recounting trauma-related memories is a productive rather than a destructive process. Individual sessions or group sessions (where a number of youngsters have been exposed to the same trauma) may be used to allow youngsters to tell and retell their recollections, feelings and dreams of the traumatic incident, using a variety of artistic media including writing, painting, drawing, drama and so forth. Video or audio recordings of trauma-related stimuli may be introduced into the sessions, and youngsters may be helped to desensitise themselves to these using procedures described in the section on phobias. Youngsters may edit their nightmares so that they experience positive rather than negative outcomes. For example, a young girl who had nightmares of being chased and caught re-edited her nightmares so that in the end she turned on her attackers and defeated them (Carr, 1995). When youngsters are helped to visualise these edited versions of their nightmares while in a relaxed state, the nightmare imagery comes to be associated with relaxed feelings and a sense of mastery. Longterm work may be based on the hypotheses about adaptation to trauma outlined in the remainder of this section. The suggestions offered below are based largely on clinical experience and accounts of case work in this area, since data on the most effective approaches to long-term management of these issues in children and adolescents are unavailable (Yule, 1994). The youngsters may attempt to retain the original world view by avoiding internal and external trauma-related stimuli and denying the impact of the traumatic incident on themselves and others. This type of avoidant adaptation leads to the exclusion of many trauma- and nontrauma-related experiences from consciousness. Inevitably this coping style, while useful in the short term, has negative long-term effects. It leads to difficulties in experiencing tender emotions, since these too become excluded from consciousness. Finally, drug abuse and alcohol abuse may offer a way for the youngster to exclude unwanted material from consciousness pharmacologically. When trauma-related events are denied or incorporated unprocessed into the world view, the goal of longer-term therapy is to help the youngsters develop a view of the world based on their total experience of life, including that part of their life which included the trauma and those parts that came before and after it. This struggle for autobiographical coherence is probably best conducted in a family therapy forum with children and young teenagers, and on an individual basis with older teenagers. Summary Fear is the natural response to a stimulus which is perceived as posing a threat to well-being, safety or security. This response includes cognitive, affective, physiological, behavioural and relational aspects. A distinction may be made between normal adaptive fears, which are premised on an accurate appraisal of the potential threat posed by a stimulus or situation, and maladaptive fears, which are based on an inaccurate appraisal of the threat to well-being. Children are referred for treatment of an anxiety problem when it prevents them from completing developmentally appropriate tasks such as going to school or socialising with friends. These different anxiety problems vary in terms of the stimuli that elicit anxiety, the patterning of hyperarousal, the significance of differing aetiological factors in their development, and their impact on interpersonal adjustment. Biological factors appear to play a role in the aetiology of some anxiety disorders. Research and clinical accounts arising from these theories point to the complex, multidetermined nature of anxiety disorders in children. Biological and psychosocial factors may predispose youngsters to develop anxiety disorders, precipitate their onset, and maintain or exacerbate these conditions.

All cell lines are described in mosaic abnormalities allergy medicine options cheap 10mg claritin, indicating the frequency of each allergy testing kansas city order claritin 10 mg with amex. Additional or missing chromosomes are indicated by or for whole chromosomes allergy symptoms during period effective claritin 10 mg, with an indication of the type of abnormality if there is a ring or marker chromosome allergy names cheap 10mg claritin fast delivery. Structural rearrangements are described by in dicating the p or q arm and the band position of the break points. Unbalanced translocations cause spontaneous abortions or syndromes of multiple 14 physical and mental handicaps 13 Figure 4. This can be used to identify the chromosomal origin of structural rearrangements that cannot be defined by conventional cytogenetic techniques. Hybridisation reveals fluorescent spots on each chromatid of the relative chromosome. Another application of this technique is in the study of interphase nuclei, which permits the study of non-dividing cells. Thus, rapid results can be obtained for the diagnosis or exclusion of Down syndrome in uncultured amniotic fluid samples using chromosome 21 specific probes. Incidence of chromosomal abnormalities Chromosomal abnormalities are particularly common in spontaneous abortions. At least 20% of all conceptions are estimated to be lost spontaneously, and about half of these are associated with a chromosomal abnormality, mainly autosomal trisomy. Cytogenetic studies of gametes have shown that 10% of spermatozoa and 25% of mature oocytes are chromosomally abnormal. The extra haploid set is usually due to fertilisation of a single egg by two separate sperm. Very few triploid pregnancies continue to term and postnatal survival is not possible unless there is mosaicism with a normal cell line present as well. All autosomal monosomies and most autosomal trisomies are also lethal in early embryonic life. Trisomy 16, for example, is frequently detected in spontaneous first trimester abortuses, but never found in liveborn infants. The incidence of unbalanced abnormalities affecting autosomes and sex chromosomes is about the same. Aneuploidy affecting the sex chromosomes is fairly frequent and the effect much less severe than in autosomal abnormalities. Unbalanced autosomal abnormalities cause disorders with multiple congenital malformations, almost invariably associated with mental retardation. Children with more than one physical abnormality and developmental delay or learning disability should therefore undergo chromosomal analysis as part of their investigation. Chromosomal disorders are incurable but most can be reliably detected by prenatal diagnostic techniques. Unfortunately, when there is no history of previous abnormality the risk in many affected pregnancies cannot be predicted before the child is born. Down syndrome Down syndrome, due to trisomy 21, is the commonest autosomal trisomy with an overall incidence in liveborn infants of between 1 in 650 and 1 in 800. Two thirds of conceptions miscarry by mid-trimester and one third of the remainder subsequently die in utero before term. The survival rate for liveborn infants is surprisingly high with 85% surviving into their 50s. Congenital heart defects remain the major cause of early mortality, but additional factors include other congenital malformations, respiratory infections and the increased risk of leukaemia. An increased risk of Down syndrome may be identified prenatally by serum biochemical screening tests or by detection of abnormalities by ultrasound scanning. Features indicating an increased risk of Down syndrome include increased first trimester nuchal translucency or thickening, structural heart defects and duodenal atresia. Less specific features include choroid plexus cysts, short femori and humeri, and echogenic bowel.

Co-morbidity rates for somatisation problems with other emotional and behavioural problems vary from 12 per cent to 20 per cent in community samples and from 23 per cent to 32 per cent in clinical samples prescription allergy medicine xyzal generic 10mg claritin amex, with the highest rate of co-morbidity being with anxiety and depression allergy partners asheville nc order 10 mg claritin with amex. Reliable prevalence rates for adjustment problems among children with chronic illnesses allergy testing york order claritin 10 mg fast delivery, such as asthma allergy treatment systems inc purchase claritin 10 mg fast delivery, diabetes, epilepsy and cancer, are unavailable. Biological theories which explain the development of somatic complaints in terms of physiological vulnerability to particular illnesses, or of general adaptation to a build-up of life stress, are of special relevance to paediatric clinical psychology. In assessing somatic complaints, particular attention should be paid to certain predisposing, precipitating, maintaining and protective factors. Physiological vulnerability; a high level of psychophysiological reactivity; exposure to sick-role behaviours of other family members; inhibited emotional expression; and a high level of suggestibility may predispose youngsters to develop somatisation problems or adjustment difficulties when faced with chronic illness. Precipitating factors for these conditions include personal or familial illness or injury; major stressful life events; or a build-up of small stressors. Maintaining factors include beliefs about the controllability of symptoms; the use of problematic coping strategies, such as denial or catastrophising; inadvertent reinforcement of sick-role behaviours; and a family environment characterised by extremities of proximity, hierarchy, conflict, triangulation and reactivity. Important protective factors include acceptance of the formulation, commitment to resolving the problems, self-efficacy, low stress and high support. A psychological approach to somatic complaints should ideally be family based and include close liaison with the referring physician so that medical aspects of the case are adequately managed. Psychological consultation should involve careful contracting for assessment; thorough child and family assessment; clear formulation; and careful contracting for treatment. Where appropriate, treatment may include psychoeducation; monitoring of symptoms; relaxation-skills training; cognitive restructuring; coaching parents in contingency management; relapse-management training; and arranging membership of a support group. She has also found that she develops persistent headaches, a problem she never had in the past. Fay has not changed school as a result of the separation but is due to go to secondary school in a few weeks. Her mood and behaviour are within normal limits and her school work is satisfactory. Write a preliminary formulation for this case outlining probable predisposing, precipitating, maintaining and protective factors. State whom you would interview and the lines of interviewing you would follow, and any additional assessment procedures you would use. For the adolescent, habitual drug abuse may negatively affect mental and physical health; criminal status; educational status; the establishment of autonomy from the family of origin; and the development of long-term intimate relationships (Newcomb and Bentler, 1988). The first is a chronic and complex case of polydrug abuse while the second involves only recreational or experimental use of two drugs. These cases differ along a number of dimensions including the pattern of drug-using behaviour; the types of drug used; the impact of the drugs used; the overall personal adjustment of the teenager; and the presence of other personal or family-based problems. Clearly drug abuse itself is not always a unidimensional problem and it may occur as part of a wider pattern of life difficulties. In this chapter, after considering the classification, epidemiology and clinical features of drug abuse, a variety of theoretical explanations concerning its aetiology will be considered along with relevant empirical evidence. The assessment of drug abuse and a family-based approach to treatment will then be given. The chapter will conclude with some ideas on how to prevent drug abuse in populations at risk. Both were polydrug abusers and had developed physiological dependence to opiates at the time of referral. History of the presenting problem They both had been using drugs since primary school, beginning with cigarettes at the ages of about 10 years as part of peer-group-based experimental drug abuse. They then used cannabis, various solvents and a variety of stimulants, but mainly dextroamphetamines. They had got to the stage where they could no longer finance their drug-taking habits and had a series of bad debts. Their whole lifestyle centred on getting and using any drugs they could find, but mainly opiates. Developmental and family history Betty and Carl had known each other from childhood. Their families were very close but disapproved of the teenage couple when they began living together about six months previously. However, in both of the families their mothers were very loyal to them, and occasionally gave them financial assistance when it was clear that they were showing withdrawal symptoms and needed a fix.

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