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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Alexander J.C. Mittnacht, MD
The complex health care needs of military servicemembers with more-severe injuries require coordination of services cholesterol chart range order lipitor 40 mg overnight delivery. Their injuries typically involve complex needs for treatment quetiapine cholesterol levels generic lipitor 40 mg otc, and supportive and rehabilitative services cholesterol medication in homeopathy generic 40 mg lipitor amex, and these needs change over time cholesterol ratio 4.4 buy cheap lipitor 40 mg. The training of recovery coordinators will be critical blood cholesterol definition discount lipitor 20mg with visa, as will training for those providing evaluation cholesterol glucose test kit discount 40 mg lipitor visa, medical, and rehabilitative services. Treating the Invisible Wounds of War: Conclusions and Recommendations 445 Strengths and Limitations Both the strengths and limitations of our study approach should be considered alongside the recommendations stemming from this work. Our survey was conducted independently and was population-based; thus, it provides estimates not previously available, obtained from populations not included in prior reports. However, the telephone-survey methodology limited respondents to those with a landbased telephone and those who lived in proximity to a military base. We used standard statistical methods to partially account for these limitations (see Chapter Four). Nevertheless, certain groups are underrepresented in our sample, and thus the overall results may not accurately generalize to the entire deployed population. Nevertheless, all of the parameters used in our model are grounded on prior literature, and we have done our best to be conservative in generating the cost predictions. In our analyses, we focused on three specific mental health and cognitive conditions that affect servicemembers and veterans post-deployment, the costs associated with addressing those conditions, and the services available post-deployment to assist in recovery. The delivery of post-deployment services is part of a larger continuum of ensuring the health of servicemembers, which includes pre-deployment screenings, education, and trainings about the potential effects of combat and deployment. It was beyond the scope of this study to fully assess the adequacy of pre-deployment screenings and training/education programs. However, these programs do require more in-depth analyses to determine their effectiveness. Finally, we relied solely on publicly available information, because requests for official data were still under review at the time of this writing. Our data show that these mental health and cognitive conditions are widespread; in a cohort of otherwise-healthy, young individuals, they represent the primary type of morbidity or illness for this population in the coming years. An exceptional effort will be required to ensure that they are appropriately recognized and treated. We briefly describe each recommendation and then discuss some of the issues that would need to be addressed for its successful implementation. Although the precise increase of newly trained providers is not yet known, it is likely to number in the thousands. These would include providers not just in specialty mental health settings but also embedded in settings such as primary care, where servicemembers already are served. Determining the exact number of providers will require further analyses of demand projections over Treating the Invisible Wounds of War: Conclusions and Recommendations 447 time, taking into account the expected length of evidence-based treatment and desired utilization rates. Additional training in evidence-based approaches for trauma will also be required for tens of thousands of existing providers. Moreover, since there is already an increased need for services, the required expansion in trained providers is already several years overdue. Such investment could be facilitated by several strategies, including the following: Adjustment of financial reimbursement for providers to offer appropriate compensation and incentives to attract and retain highly qualified professionals and ensure motivation for delivering quality care. Development of a certification process to document the qualifications of providers. To ensure that providers have the skills to implement high-quality therapies, substantial change from the status quo is required. Rather than rely on a system in which any licensed counselor is assumed to have all necessary skills regardless of training, certification should confirm that a provider is trained to use specific evidence-based treatment for specific conditions. Providers would also be required to demonstrate requisite knowledge of unique military culture, military employment, and issues relevant to veterans (gained through their prior training and through the new training/certification we are recommending). Expansion of existing training programs for psychiatrists, psychologists, social workers, marriage and family therapists, and other counselors. Programs should include training in specific therapies related to trauma and to military culture. This training could occur in coordination with or through the Department of Health and Human Services. Training should be standardized across training centers to ensure both consistency and increase fidelity in treatment delivery. Linkage of certification to training to ensure that providers not only receive required training but also are supervised and monitored to verify that quality standards are met and maintained over time. Evaluation of training efforts as they are rolled out, so that we understand how much training is needed and of what type, thereby ensuring delivery of effective care. Creating an adequate supply of well-trained professionals to provide care is but one facet of ensuring access to care. Many servicemembers are reluctant to seek services for fear of negative career repercussions. Policies must be changed so that there are no perceived or real adverse career consequences for individuals who seek treatment, except when functional impairment. Primarily, such policies will require creating new ways for servicemembers and veterans to obtain treatments that are confidential, to operate in parallel with existing mechanisms for receiving treatment. We are not suggesting that the confidentiality of treatment should be absolute; both military and civilian treatment providers already have a legal obligation to report to authorities/commanders any patients that represent a threat to themselves or others. However, information about being in treatment is currently available to command staff, even though treatment itself is not a sign of dysfunction or poor job performance and may not have any relationship to deployment eligibility. Providing an option for confidential treatment has the potential to increase total-force readiness by encouraging individuals to seek needed health care before problems accrue to a critical level. We believe that this option would ultimately lead to better force readiness and retention, and thus be a beneficial change for both the organization and the individual. This recommendation would require resolving many practical challenges, but it is vital for addressing the mental health problems of servicemembers who, out of concern for their military careers, are not seeking care. Specific strategies for facilitating careseeking include the following: Developing strategies for early identification of problems that can be confidential, so that problems are recognized and care sought early before the problems lead to impairments in daily life, including job function or eligibility for deployment. Developing ways for servicemembers to seek mental health care voluntarily and off-the-record, including ways to allow servicemembers to seek this care off-base if they prefer and ways to pay for confidential mental health care (that is not necessarily tied to an insurance claim from the individual servicemember). Thus, the care would be offered to military personnel without mandating disclosure, unless the servicemember chooses to disclose use of mental health care or there is a command-initiated referral to mental health care. Treating the Invisible Wounds of War: Conclusions and Recommendations 449 Separating the system for determining deployment eligibility from the mental health care system. This may require the development of new ways to determine fitness for duty and eligibility for deployment that do not include information about mental health service use. Deliver proven, evidence-based care to servicemembers and veterans whenever and wherever services are provided. Providing evidence-based care is not only the humane course of action but also a cost-effective way to retain a ready and healthy military force for the future. We suggest requiring all providers who treat military personnel to use treatment approaches empirically demonstrated to be effective. Evidence-based approaches to resilience-building and other programs need to be enforced among informal providers, including promising prevention efforts pre-deployment, noncommissioned officer support models in theater, and the work of chaplains and family-support providers. Such programs could bolster resilience before mental health conditions develop, or help to mitigate the long-term consequences of mental health conditions. Some key transformations may be required to achieve this needed improvement in the quality of care: 450 Invisible Wounds of War the "black box" of psychotherapy delivered to veterans must be made more transparent, making providers accountable for the services they are providing. Veterans should be empowered to seek appropriate care by being informed about what types of therapies to expect, the benefits of such therapies, and how to evaluate for themselves whether they are receiving quality care. A monitoring system could be used to ensure sustained quality and coordination of care and quality improvement. Transparency, accountability, and training/ certification, as described above, would facilitate ongoing monitoring of effectiveness that could inform policymaking and form the basis for focused qualityimprovement initiatives. Additionally, linking performance measurements to reimbursement and incentives for providers may also promote delivery of quality care. This knowledge is required both to enable the health care system to respond effectively and to calibrate how disability benefits are ultimately determined. Greater knowledge is needed to understand who is at risk for developing mental health problems and who is most vulnerable to relapse, and how to target treatments for these individuals. We need to document how these mental health and cognitive conditions affect families of servicemembers and veterans so that appropriate support services can be provided. We need sustained research into the effectiveness of treatments, particularly treatments that can improve the functioning of individuals who do not improve from the current evidencebased therapies. Further, to adequately address knowledge gaps will require funding mechanisms that encourage longer-term research that examines a broader set of issues than can be financed within the mandated priorities of an existing funder or agency. These agencies have limited research activities relevant to military and veteran populations, but these populations have not always been prioritized within their programs. Ideally, such a study would gather data pre-deployment, during deployment, and at multiple time points post-deployment. The study should be designed so that its findings can be generalized to all deployed servicemembers while still facilitating identification of those at highest risk, and it should focus on the causal associations between deployment and mental health conditions. These data would greatly inform how services are arrayed to meet evolving needs within this population of veterans. They would also afford a better understanding of the costs of these conditions and the benefits of treatment so that the nation can make fiscally responsible investments in treatment and prevention programs. More research is also needed to evaluate innovative treatment methods, since not all individuals benefit from the currently available treatments. Many new initiatives and programs designed to address psychological and cognitive injuries have been put into place, ranging from screening programs and resiliency training, to use of care managers and recovery coordinators, to implementation of new therapies. Each of these initiatives and programs should be carefully evaluated to ensure that it is effective and is improving over time. The prevalence of these injuries is relatively high and may grow as the conflicts continue. And longterm negative consequences are associated with these injuries if they are not treated with evidence-based, patient-centered, efficient, equitable, and timely care. The systems of care available to address these injuries have been improved significantly, but critical gaps remain. The nation must ensure that quality care is available and provided to its military veterans now and in the future. As a group, the veterans returning from Afghanistan and Iraq are predominantly young, healthy, and productive members of society. In the absence of knowing, these injuries cause great concern for servicemembers and their families. These veterans need our attention now, to ensure a successful adjustment post-deployment and a full recovery. System-level changes are essential if the nation is to meet not only its responsibility to recruit, prepare, and sustain a military force but also its responsibility to address Service-connected injuries and disabilities. Treating the Invisible Wounds of War: Conclusions and Recommendations 453 References Department of Veterans Affairs, Office of Policy, Planning, and Preparedness. Evaluation of Services for Seriously Mentally Ill Patients in the Veterans Health Administration of the Department of Veterans Affairs, Revised Statement of Work. However, publications from the American Academy of Pediatrics may the American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Stanley earned his Bachelor of Arts degree from New York University and then his Doctor of Medicine degree from the State University of New York Medical School in Brooklyn. Stanley was elected to the Institute of Medicine in 2005 and to the French Academy of Medicine in 2007. Because of his passion and his genius, countless lives across scores of years have been kept whole. At back on the road that he has traveled, and guided those in attendance to "be patient. This edition of the Red Book is dedicated to Stanley as a small thank you on behalf of all the children and pediatricians whose lives are better through his contributions. With the limited time available to the practitioner, the ability to quickly obtain current, accurate, and easily accessible information about new vaccines and vaccine recommendations, emerging infectious diseases, new diagnostic modalities, and treatment recommendations is essential. Publishing is rapidly evolving, so the value of the Red Book is continuously enhanced by the Red Book Online ( Another important resource is the visual library of Red Book Online, which has been updated and expanded to include more information on epidemiology of infectious diseases. The Committee on Infectious Diseases relies on information and advice from many experts, as evidenced by the lengthy list of contributors to Red Book. As noted in previous editions of the Red Book, some omissions and errors are inevitable in a book of this type. This edition of the Red Book is based on information available as of February 2015. The Red Book is formatted as hard copy, mobile app, and online Web version, with the electronic versions containing links to supplemental information, including visual images, graphs, maps, and tables. Soon after publication of each Red Book edition, all Red Book chapters are sent for updates to primary the 2015 Red Book, 62% of primary reviewers were new to this process, ensuring that the most up-to-date information has been included in this new edition. The chapter then is disseminated to content experts at chapters for their additional edits as needed, following which it again is returned to the assigned Associate Editor for harmonization and incorporation of edits as appropriate. In all, more than 1000 hands have touched the 2015 Red Book prior to its publication! That so many contributors dedicate so much time and expertise to this product is a testament to the role the Red Book plays in the care of children. In some cases, other committees and experts may differ in their interpretation of data and resulting recommendations. In making recommendations in the Red Book, the committee acknowledges differences in viewpoints by use of the phrases "most experts recommend. Inevitably in clinical practice, questions arise that cannot be answered easily on the basis of currently available data.
Scoring: Age equivalents cholesterol ratio or total cheap 40mg lipitor with mastercard, scaled scores cholesterol test fasting requirements order 20 mg lipitor amex, developmental quotient cholesterol molecule generic lipitor 5 mg online, z-scores cholesterol ratio vs total order lipitor 5mg, T-scores cholesterol levels table uk buy lipitor 40mg on line, normal curve equivalents cholesterol levels range uk cheap 20mg lipitor free shipping, percentile ranks, confidence intervals. Subscales: Adaptive (Self-Care and Personal Responsibility); Personal-Social (Adult Interaction, Peer Interaction, and Self-Concept and Social Role); Communication (Receptive and Expressive); Motor (Gross, Fine, and Perceptual); Cognitive (Attention and Memory, Reasoning and Academic Skills, and Perception and Concepts). Children with disabilities were not included in the norming sample, but were included in reliability and validity studies. Scores Available: Scaled scores, composite scores, and percentile ranks for each subscale. Growth scores and developmental age scores for the cognitive, language, and motor scales. Subscales: Cognitive, language (receptive, expressive, total), motor (fi ne, gross, total), social-emotional, adaptive. Norming Sample: For the cognitive, language and motor scales: 1,700 children representative U. For the social-emotional scale, 456 children; for the adaptive behavior scale, 1,350 children. Scores Available: T-scores and percentiles for general clinical populations Subscales: Aggression, Conduct Problems, Atypicality, Locus of Control, Social Stress, Anxiety, Depression, Somatization, Sense of Inadequacy, Self-Esteem, Self-Reliance, Attention Problems, Learning Problems, Attitude to School, Attitude to Teachers, Sensation Seeking, School Problems, Inattention-Hyperactivity, Adaptability, Social Skills, Leadership, Study Skills, Relations with Parents, Interpersonal Relations, Withdrawal, Anger Control, Bullying, Developmental Social Disorders, Emotional Self-Control, Executive Functioning, Negative Emotionality, Resiliency, Social Stress, Ego Strength, Mania, Test Anxiety. Subscales: Strength Index (Composite Score), plus Interpersonal Strength, Family Involvement, Intrapersonal Strength, School Functioning, Affective Strength. The demographic characteristics of the standardization sample are generally equivalent to the most recent 2001 U. Examiner administers the three subtests in English first; any item that was answered incorrectly or skipped is then administered in the native language. Subscales: Overall verbal ability (bilingual), English language proficiency; Norming Sample: 8,818 subjects in more than 100 geographically diverse U. Includes a parent form to use in reporting results to parents; provides suggestions for home-activities. Scores Available: Raw scores, percent correct, performance range, and percentiles by grade, with separate norms for fall and spring testing for grades K, 1, and 2 Subscales: More than 6,000 students in the fall testing session and 4,000 in the spring session, representative of the U. Scores Available: Subtest and Composite, Percentile Ranks, Scaled scores, Standard Scores, Confidence Intervals and Concept Age Equivalents. Subscales: Colors, Letters, Numbers/Counting, Sizes, Comparisons, Shapes, Direction/Position, Self/Social Awareness, Texture/Materials, Quantity, Time/Sequence Norming Sample: 1,100 children, representative of the U. Scores Available: For each subtest and composite: scale scores, stand scores, confidence intervals, percentile rank, age equivalent, descriptive categories. Scores Available: Standard scores, percentile ranks, age equivalents, criterion-referenced cut-points, item analysis Subscales: Composites: Core Language, Receptive Language, Expressive Language, Language Content, Language Structure, and Working Memory. Subtests: Concepts and Following Directions, Core Language, Expressive Language, Expressive Vocabulary, Familiar Sequences, Formulated Sentences, Language Content, Language Memory, Language Structure, Number Repetition, Phonological Awareness, Rapid Automatic Naming, Recalling Sentences, Receptive Language, Semantic Relationships, Sentence Assembly, Sentence Structure, Understanding Spoken Paragraphs, Word Associations, Word Classes-Receptive, Word Classes-Expressive, Word Defi nitions, Word Structure Norming Sample: 2,650 students, representative of the U. Scores Available: Scaled scores, standard scores, percentile ranks, confidence intervals, criterion-referenced cutpoints, item analysis. Subscales: Composites: Core Language, Receptive Language, Expressive Language, Language Content, Language Structure. Subtests: Sentence Structure, Word Structure, Expressive Vocabulary, Concepts and Following Directions, Recalling Sentences, Basic Concepts, Word Classes, Recalling Sentences in Context, Phonological Awareness, Pre-Literacy Rating Scale, Descriptive Pragmatics Profi le Norming Sample: 800 children, representative of U. If the checklist indicates concern, caregiver completes the Caregiver Questionnaires and the professional administers a Behavior Sample. Subscales: Social Composite (Emotion and Eye Gaze, Communication, Gestures); Speech Composite (Sounds, Words); Symbolic Composite (Understanding, Object Use) Norming Sample: Infant Toddler Checklist: 2,188 children; Caregiver Questionnaire: 790 children; Behavior Sample: 337 children. Examples include: Executive Functioning, Learning Problems, Aggression, Peer Relations, Family Relations, Inattention Hypteractivity/Impulsivity, Oppositional Defiant Disorder, Conduct Disorder Norming sample: Approximately 2,900 parent or teacher forms from the general population and over 1,000 parent or teacher forms from the clinical population; representative of the general U. Ratings are made on a 4-point scale and are based on the past month Scores Available: T-Scores, Percentiles, and Standard Error of Measurement Subscales: See Technical Manual for full list. Examples include: Emotional Distress, Aggressive Behaviors, Academic Difficulties, Hyperactivity/Impulsivity, Social Problems, Violence Potential, Oppositional Defiant Disorder, Major Depressive Episode, Generalized Anxiety Disorder, Bullying (Perpetration, Victimization), Post Traumatic Stress, Phobia. Norming sample: Approximately 2,900 parent or teacher forms from the general population and over 1,000 parent or teacher forms from the clinical population; representative of the general U. Scores Available: Subtest raw scores, subtest age equivalents, subtest standard scores, a quotient standard score, and percentiles. Subscales: Cognition, Communication, Social/Emotional Development, Physical Development, and Adaptive Behavior Norming Sample: National sample of 1269 individuals, residing in 27 states, comparable 1996 U. Census in terms of geographic region, gender, race, rural or urban residence, ethnicity, family income, educational attainment of parents, and disability status. Scores Available: Ability scores, T scores, cluster scores, composite scores and percentile ranks. In addition, confidence intervals are available for the cluster and composite scores; standard error of measurement information and age equivalents are provided for the subtest ability scores. For children ages 5:0-8:11 years, there is also a School Readiness cluster that measures three sets of abilities related to early school success and failure. Subscales: Core battery: Verbal, Nonverbal, and Spatial reasoning; Diagnostic subtests: Copying, Early Number Concepts, Matching Letter-Like Forms, Matrices, Naming Vocabulary, Pattern Construction, Phonological Processing, Picture Similarities, Rapid Naming, Recall of Designs, Recall of Digits, Recall of Objects, Recall of Sequential Order, Recognition of Pictures, Sequential and Quantitative, Verbal Similarities, Speed of Information Processing, Verbal Comprehension, Word Defi nitions Norming sample: May be available in Technical Manual. Note: Primary purpose is diagnostic, but reported to be useful in informing instruction. Scores Available: Grade-based percentiles for fall, winter and spring; also cut-points for emerging/below basic, basic, proficient. Norming sample excluded students who were receiving special education and those identified as Limited English Proficient. The sample of children ages 2 to 18 included representative proportions of children with special needs. The examiner can collect information for use in completing tool using a 25-item parent interview form and from direct observation of the child. Scores Available: Subscale standard scores, percentile ranks, Autism Index, Probability of Autism classification (very likely, possibly, unlikely). Subscales: Stereotyped Behaviors, Communication, Social Interaction Norming Sample: 1,107 individuals with autism in 48 states, representative of the U. Note: Designed to help in the identification and diagnosis of autism and estimate the severity of the disorder. Scores Available: Raw scores, age-based standard scores, test-age equivalents Subscales: Sounds-in-Words, Sounds-in-Sentences, Stimulability. Subscales: 8 domains: Gross Motor, Fine Motor, Relationship to Inanimate Objects (Cognitive), Language/ Communication, Self-Help, Relationship to Persons, Emotions and Feeling States (affects), and Coping Behavior Norming Sample: Sample of 100 children, not nationally representative, using the fourth phase of the assessment. Scores Available: Scores calculated for each "quadrant" (low registration, sensation seeking, sensory sensitivity, sensation avoiding, low threshold). For birth to 6 months, cut-points are provided for "typical performance" or "consult and follow-up. Subscales: General processing, auditory processing, visual processing, tactile processing, vestibular processing, oral sensory processing. Norming Sample: 809 children without disabilities for creation of the scoring structure. Children with disabilities were included in other aspects of the standardization process. Subscales: Three problem domains (Externalizing, Internalizing, Dysregulation) and one competence domain with three to six subscales per domain. Scores Available: T-scores and percentile ranks divided by 6-month age bands and gender. Total number of items in the Complete battery varies from 146 (Level 5) to 515 (Level 14); Core and Survey Batteries have fewer items. Scores Available: Raw scores, percent-correct scores, grade equivalents, developmental standard scores, percentile ranks, stanines, and normal curve equivalents are available for most content areas. Subscales: For ages 5 - 8: Vocabulary, Word Analysis, Listening, Language, Reading Words, Reading Comprehension, Spelling, Mathematics, Math Concepts, Math Problems, Math Computation, Social Studies, Science, Sources of Information, Composite, Reading Total, Math Total, Reading Profile Total, Survey Battery Total, Core Total. Norming Sample: Approximately 170,000 students in spring; 76,000 students in fall. Scores Available: Age-based standard scores, age equivalents, and percentile ranks, Score Summary Table, Graphic Profi le, Narrative Report, Planned Clinical Comparisons, Ability/Achievement Discrepancy Subscales: Short Term Memory, Visual Processing, Long-Term Storage and Retrieval, Fluid Reasoning, and Crystallized Ability, scales, yielding a Fluid-Crystallized Index composite. Scores Available: Standard scores, 90% confidence intervals, percentile ranks, descriptive categories, and age-equivalents. Scores Available: Age-based standard scores, percentile ranks, descriptive categories, and age equivalents. Performance on the Articulation Survey subtest can be interpreted using descriptive categories (Normal, Below Average, Mild Difficulty, or Moderate to Severe Difficulty) and item error analysis procedures. Subscales: Expressive Skills, Receptive Skills, Number Skills, Letter & Word Skills, plus an Early Academic and Language Skills composite. Subscales: Reading Composite: Letter and Word Recognition, Reading Comprehension; Other Reading Related subtests: Phonological Awareness, Nonsense Word Decoding, Word Recognition Fluency, Decoding Fluency, Associational Fluency, Naming Facility; Math Composite: Math Concepts and Applications, Math Computation; Oral Language Composite: Listening Comprehension, Oral Expression; Written Language Composite: Written Expression, Spelling; Other Composites: Comprehensive Achievement, Decoding, Oral Fluency, Reading Fluency, Sound-Symbol Norming Sample: 3,025 children, closely representing U. Scores Available: Standard Score, Percentiles, Test-Age Equivalents, and percent-of-occurrence. Subscales: Fine Motor (Writing, Manipulation), Cognitive (Counting, Matching), Language (Naming, Comprehension), Gross Motor (Body Movement, Object Movement) Norming Sample: 2,099 children (1,124 English-speaking; 975 Spanish-speaking) from five areas throughout the U. Scores Available: Raw scores, standard scores, descriptive ratings and percentages based on standard scores, percentile ranks, age equivalents, and grade equivalents. Subscales: Isolating Phoneme Patterns, Tracking Phonemes, Counting Syllables, Tracking Syllables, Tracking Syllables and Phonemes. Scores Available: Standard scores, percentiles, age equivalents, growth scores, and growth score profi le. Derived scores are recorded on the Summary Report and may be plotted to indicate patterns of strengths and weaknesses. Subscales: Expressive Language, Social-Emotional Development, Social-Emotional Temperament, Self-HelpAdaptive, Cognitive Battery, and Gross Motor Skills. Scores Available: Percentile ranks, stanines, normal curve equivalents, scaled scores, and standard scores. Subscales: Beginning Reading Skill Area (Visual Discrimination, Beginning Consonants, Sound-Letter Correspondence, Aural Cloze with Letter), Story Comprehension, Quantitative Concepts and Reasoning, Prereading Composite Norming Sample: May be available in the Technical Manual. Scores Available: T score; confidence intervals, percentile rank, age equivalent, developmental stage, descriptive category, profi le analysis; an early learning composite can be derived Subscales: Gross Motor, Visual Reception, Fine Motor, Receptive Language, Expressive Language. Population with regard to race, socioeconomic status, region, and community size (1990 U. Subscales: Reflexes (8 items), Stationary (30 items), Locomotion (89 items), Object Manipulation (24 items), Grasping (26 items), Visual-Motor Integration (72 items); plus Fine Motor, Gross Motor and Total Motor Quotients. Record forms include a Developmental Score Profi le for profiling age and grade equivalents and a Standard Score Profi le for profiling for age- or grade-based standard scores. Subscales: General Information, Reading Recognition, Reading Comprehension, Mathematics, Spelling, Written Expression. Norming Sample: Varied by subtest from low of 1,285 for Written Expression to high of 2,809 for Mathematics Application. Scores Available: Raw scores are converted to age equivalencies, percentile ranks, and standard scores. Subscales: Rhyming, segmentation, isolation, deletion, substitution, blending, graphemes, decoding, invented spelling Norming Sample: 1,582 reflecting the national school population with regard to race, gender, age, and educational placement (2004 Census). Note: Manual provides information on using test scores for instructional planning. Scores Available: Standard scores, age equivalents, and percentile ranks, Pictorial Intelligence Quotient Subscales: Verbal abstractions, form discrimination, and quantitative concepts Norming Sample: 970 children in 15 states, intended to be representative of the U. All items use a multiple-choice format, allowing examinees to indicate their choice via pointing or eye gaze; no verbal expressive skill required. Basic understanding of the principles of education and psychological testing needed for interpretation. Scores Available: Raw scores are converted to standard scores, percentile ranks, and risk levels. Social Skills section is further broken down into 3 subscales: Social Cooperation, Social Interaction, and Social Independence. Problem Behaviors section is broken into two subscales: Externalizing Problems and Internalizing Problems. In addition, 5 supplementary problem behavior subscales are available for optional use, including Self-Control-Explosive, Attention ProblemsOveractive, Antisocial-Aggressive, Social Withdrawal, Anxiety-Somatic Problems). Scores Available: Standard scores, percentile ranks, and age equivalencies Subscales: Norm referenced: Matching, Analysis, Reordering, Reasoning, Receptive Mode, Expressive Mode, plus a Discourse Ability Score gives an overall estimate of performance. Scores Available: Standard scores, percentile ranks, and age equivalents are available for birth to 11 months (3-month intervals) and 1 year through 6 years, 11 months (6-month intervals). The Articulation Screener provides age-appropriate cut-points that help a clinician determine if further articulation testing is advisable. Three supplemental assessments: Language Sample Checklist, Articulation Screener, and Caregiver Questionnaire. Norming Sample: 2,400 children at 357 sites in 48 states, representative of the U. Note: Designed to measure the development of cognitive processes that are critical to learning math skills and actual math performance. Examples include: Alphabet Writing, Copying, Compositional Fluency; Expository Note-Taking, Expository Report Writing, Verbal Working Memory, Written Sentences, Pseudoword Decoding, Rapid Automatized Naming-Letters, Rhyming. Note: Developed to facilitate the creation of assessment driven interventions in the areas of reading and writing.
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Schoenberg 2004 ideal cholesterol ratio for an individual cheap 5mg lipitor with mastercard, for detailed review and description of these and other language tests cholesterol steroid discount 5 mg lipitor. In general average cholesterol during pregnancy generic 40 mg lipitor fast delivery, the advantage of detailed neuropsychological assessment of language functions allows for quantification of language function in terms of performance compared to population normative data cholesterol test machine price in india order 10mg lipitor fast delivery, which may be expressed in terms of percentiles cholesterol guidelines 2015 40 mg lipitor. Such a detailed assessment allows for the identification of subtle expressive and/or receptive language deficits that may not be appreciated in a bedside assessment cholesterol levels for 35 year old man order lipitor 10mg free shipping. We recommend an outpatient neuropsychological evaluation to assess expressive and receptive speech along with repetition and naming. Common measures of expressive speech include carefully listening to the patient describe his/her problems or history, and various oral or written verbal fluency tests. Typical measures include phonemic verbal fluency and semantic verbal fluency tests. Comprehension can be assessed with measures assessing increasing complex directions. Appendix A Acute Assessment of Language and Prosody Receptive language and prosody Simple receptive language Simple Yes/No question Is it winter? Schoenberg Discourse/spontaneous expressive speech Structured Show a picture; ask patient to describe what is happening Unstructured Ask patient what he/she did/does for work and give the details. Schoenberg Abstract the capacity to encode, retain and retrieve information is essential to the evolution of all living animals. From the ameba to ourselves, learning from interaction with our environment is critical to adaptation to the stimuli that influence our well being. The human brain is masterful at recognizing patterns of recurrence, be they sensory, motor or cognitive. This process of pattern recognition produces engrams which are the building blocks of concepts and organization which facilitate retrieval. Through this chapter, we will discuss models of processing and outline the essential elements for memory. We will discuss the anatomical correlates of memory and discuss how damage to many parts of the brain can have a direct or secondary effect on memory functioning. Several syndromic patterns of memory loss are reviewed below and recommendations given regarding possible etiologies for these observed memory scores. The factors which influence memory including encoding, storage and retrieval will be addressed. Finally, in this chapter we will discuss how to perform an assessment of memory functions which will allow the clinician to determine if problems in memory are present and if more detailed assessment of memory functions is indicated. Additional detailed information regarding the impact that different etiologies can have on memory functioning are discussed throughout this text. As with many cognitive functions beyond the basic sensory, perceptual and motor systems, memory is dependent on prerequisite skills for accurate assessment and determination of the etiology of a deficit. Accurate assessment of memory hinges on the adequacy of sensory input, perceptual skill, motor output and attentional capacity. Factors which influence these prerequisite skills can produce a profound impact on memory. In addition, some internal cognitive aspects of functioning such as reasoning and organization produce secondary effects on measured memory skills. In addition to these factors, assessment of memory must consider the emotional functioning of the person being assessed. Severe psychopathology such as schizophrenia or bipolar disorder can have an obvious and profound effect on memory; however, J. Schoenberg even mild depression and situational anxiety can produce subtle but predictable effects on memory performance which may be detrimental or enhancing. While there are several models, common themes include three stages involving encoding, storage and retrieval. The process by which information is transferred from encoding to storage depends on the nature of the material which is to be recalled. There are three basic memory stages: sensory storage, short-term memory, and long-term memory. Each has been subdivided into more refined aspects of memory systems, and briefly reviewed below. Even in neurologic conditions, remote memory is almost always better than recent memory. It refers to the point of time that auditory, visual, gustatory, tactile or olfactory information is initially registered as a conscious phenomenon. This stage of memory is very short in duration, lasting milliseconds to seconds, and decays rapidly if no further attending to the stimuli is done. The information in sensory storage must be attended to before being transferred to short-term memory. This capacity can easily be expanded through superimposing organization such as chunking. The array of letters on the left may appear as 16 individual bits of information and difficult to memorize while the array on the right has been altered to facilitate semantic clustering thus the number of items to be recalled is reduced to 7. Without imposing some process such as organizing or rehearsal, information in short-term memory is quickly forgotten. Several processes facilitate the consolidation of information into long-term memory. The simple act of rehearsal facilitates transfer to longterm memory, but the emotional strength of the material also facilitates consolidation. Material which is associated with emotional experiences (positive or negative) is more easily encoded and facilitates retrieval. The level at which information is processed makes encoding information more efficient. Schoenberg retrieval of words is facilitated when individuals are asked if the words describe themselves compared to being asked if the word was a positive or negative characteristic. Elaborating the material to be learned also associates it with previously acquired information and again facilitates transfer to long-term memory. Yet other processes can affect memory consolidation, including state and environmental learning. State-depending learning reflects improved learning and recall when the emotional and physical state of the individual are congruent. Additionally, the saliency of the material to be recalled influence encoding and retrieval. For example, material which is learned in one physical environment is recalled much better in the same environment or a highly similar environment. This phenomenon is appreciated when examining the discrepancy when recalling high school events while at your old high school. The graph below demonstrates the stages of memory and processes by which information is transferred from one stage to another and notes some of the factors which impact consolidation of information into long-term memories (Fig. Sensory Storage Attention ShortTerm Memory Processing no attention Rehearsal Elaboration Emotionally charged Incidentalintentional Statedependence effects Encoding Long-term Memory forgetting no processing forgetting Fig. These memory types are referred to as Declarative (or Explicit) memory and Non-declarative (or Implicit) memory. This type of memory is also termed Explicit memory, and the two terms (declarative and explicit are often used interchangeably). Declarative (or explicit) memory is divided into Episodic memory and Semantic memory (Squire and Zola 1996). This is the memory for what you did yesterday, where you went on your first date, or your first car. Episodic memory is the active recall of the learning event, while semantic memory recall is retrieval of a fact, and does not require one to recall the autobiographical event when the material was learned. Semantic memory is unable to determine a particular place and time the information was learned. The unique aspects of this remembered material is the conscious effort involved in the learning 184 J. This is the conscious material that can be recalled which is unique to the experiences of the individual. Declarative memory is the type of memory which we most commonly refer to when discussing memory in a clinical setting. And it is episodic memory which is of particular emphasis in neuropsychological assessments. Nondeclarative (Implicit) Memory Nondeclarative memory refers to memory for skills and procedures which are learned and recalled. Evidence for such a memory system is found by the efficiency and skill gains which accumulate for even complex activities. The origins of the learning process are often lost such as learning to speak or riding a bicycle, but the transfer of learning must occur for such behaviors to be demonstrated and recalled. Nondeclarative memory includes a number of acquired motor skills, but also includes a great number of very complex behaviors such as playing a musical instrument or driving a car. The adaptation of humans to perform repetitive skills with precision and very little conscious processing is astounding. The next section provides an overview of common terms used to describe memory problems followed by a brief review of neuroanatomical correlates of memory. Classically, amnesia describes the loss of memory while other neuropsychological functions remain intact. The individual exhibits a profound inability to learn new material, in which declarative memory functions are largely lost. Anterograde Amnesia Anterograde amnesia describes the inability to encode new material since the event onset or injury. With pure anterograde amnesia, the individual is able to recall previous events, up to very close to the time of the event leading to anterograde amnesia (see below for common causes of anterograde amnesia). The most common is an inability to recall immediate previous information from before the event. Retrograde amnesia is frequently temporally graded, such that memories immediately before the event leading to amnesia are markedly poor while memories farther removed from the event (moving increasingly early in recent experience) may be better recalled. Typical Patterns of Memory Loss A typical pattern for amnesia is for anterograde to predominate while retrograde amnesia is temporally graded by hours, days, weeks, months, or rarely years. Anterograde amnesia may be temporally limited, that is recovery of normal memory functions after a period of hours, days, weeks, or rarely months to years. Alternatively, some conditions can result in a permanent amnestic syndrome involving anterograde amnesia and usually some retrograde amnesia. Cases of predominate retrograde amnesia with preserved anterograde amnesia are very rare, but have been reported. Neuropsychological assessment includes assessment of various components of (mostly) declarative memory, but some aspects may also assess nondeclarative memory function. Common terms to describe domains of memory that may be impaired within a neuropsychological evaluation include: recent memory, remote memory, long-term memory, short-term (immediate) memory, working memory, and semantic memory. Memory Terms: A Brief Review Delayed recall (recall of a previously exposed material after some period of delay, typically less than 1 hour) Delayed recognition (refers to recognition of stimuli previously presented). Recent memory is a term to describe memory for events that occurred within the past few days; however, there is disagreement as to the demarcation of recent and remote memory Remote memory describes memory for events that occurred before the present. Traditionally, this term may be used to describe the memory of events or experiences of 186 J. Schoenberg an individual in the distant past; however, as noted above, the demarcation regarding how far in the past is a matter of debate. Performance after a 30-minute delay is highly correlated with memory function after days to weeks, although some temporal forgetting or decay does occur. Short-term memory describes memory scores obtained usually after a proceeding recall trial. Working memory is a term to describe immediately processed information before it is sent to short term memory. Consolidation refers to the process of transferring information from immediate (short-term memory) to long-term memory. Retrieval refers to the process of retrieving information from long-term memory; that is, conscious recollection. Primacy effect refers to the observation of recalling the first part of to be learned material. May reflect learning the first initial items in word list or the first part of a verbal story or the first series of pictures or presented figures in a series of to be learned material. Recency effect refers to the enhanced recall of the last part (most recent) of to be learned items. Verbal Semantic Memory (also termed Verbal Contextual memory) describes memory for short stories that are typically auditorily administered (read out loud). List Learning refers to immediate and delayed recall for a rote memorization of a word list. Visual Memory (also termed NonVerbal memory) describes memory for nonverbal material developed to avoid being easily verbally encoded such as faces, geometric figures, or spatial locations.
Manner of exchange of student progress and staff implementation data (how will data go back and forth? Content of data to exchange about student progress and staff implementation: Include what outbound data to exchange cholesterol levels while breastfeeding cheap lipitor 20 mg overnight delivery, under which conditions cholesterol lowering foods natural discount lipitor 10 mg otc, and what inbound response to that data should occur cholesterol weight buy lipitor 10mg without a prescription. Whenever there are many stakeholders cholesterol test and alcohol consumption cheap 5 mg lipitor mastercard, or when there is doubt that all implementers will continue interventions for the time required to change the behavior cholesterol levels in pregnancy order lipitor 5mg on-line, it is especially necessary to fully describe how the communication will occur and how each player will respond to the communication when received what are some cholesterol lowering foods that taste good cheap lipitor 5 mg online. For example, what communication will the parent send back to the teacher after reviewing a daily report card? How will the administrator respond back to the counselor when a report of problem behavior is received? This requires considering the communication dyads, method, frequency, content and manner of the exchange. This well designed system provides prompting and reinforcement for continued program implementation. Some of the identified problem behavior(s) are not observable and measurable Components to Evaluate 2 Points 1 Point 0 Point No problem behavior is stated in observable and /measurable terms A. One or more predictors from environmental categories are given, but with no details. No predictors of problem behavior from any of the environmental categories are given, or predictors are from other environments and are not triggers in the current environment, or internal thoughts or, presence of an internal state or behavioral history or disability is described. Analysis of what supports the problem behavior is logically related to predictors 6 to 5 Half or more features of the environment targeted for change (line 6) are logically related to one or more identified predictors (line 5) Less than half of the features of the environment targeted for change (line 6) are logically related to one or more identified predictors (line 5). None of the predictors (line 5) are logically related to (line 6) the summary as to why the problem behavior is occurring in the specific situation. Environmental change is logically related to what supports the problem behavior 7 to 6 One or more environmental changes, i. All identified function(s) are identified in terms of 1) getting something or 2) rejecting: escaping, protesting, or avoiding something (line 8) But not all are logically related to identified predictors for behavior (line 5). Score zero if one or more functional contaminators are present (a) revenge, (b) vengeance, (d) control, (e) power F. Team coordination in implementation 7, 10, 11, 12, 14 All implementers and information exchangers are identified and all responsibilities are specified. No reactive strategy contaminator is described on the plan: catharsis for aggression, or no managing safely strategy given on the plan for aggressive verbal or physical behavior listed (line 5). Considerations: Specify in observable, measurable terms, what the behavior will look like (a) an increase in desired (b) a decrease or stop undesired Do not use self-esteem enhanced, feelings of anger reduced which are difficult/impossible to accurately measure. Considerations: Data collection: Recording in record book, teacher-made rating sheet, random/continuous time sampling,? Specify in observable, measurable terms, the new, socially more acceptable behavior that achieves the same outcome for the student as the problem behavior Repeat the hypothesized function: 1. Data collection: Recording in record book, teachermade rating sheet, random/continuous time sampling,? Often if a problem is at a particular level of severity, or a positive behavior is beyond expectations Transmittal Considerations: paper to office file, email, paper student carries, telephone direct, telephone answering machine (a) Continuous? C-27 Behavior Support Plan Contaminators Contaminators to Avoid: Results in Automatic Scores of 0 Components to Evaluate Rationale E. Problem Behavior Predictors of Behavior Analyzing What is Supporting Problem Behavior Environmental Changes Predictors Related to Function Function Related to Replacement Behaviors Teaching Strategies Reinforcement Reactive Strategies Goals and Objectives Team Coordination Communication Total Score (X /24) A well developed plan embodies best practice: a careful analysis of the problem, comprehensive interventions and a team effort to teach new behavior and remove elements in the environment associated with problem behavior. Fewer than 12 points = Weak Plan this plan may affect some change in problem behavior but the written plan only weakly expresses the principles of behavior change. Communication Total Score (X /24) Suggestions for improving this plan: A well developed plan embodies best practice: a careful analysis of the problem, comprehensive interventions and a team effort to teach new behavior and remove elements in the environment associated with problem behavior. The following additional points will enhance clarity and quality of the written product. Does the plan score in the good or superior range, with evidence that the plan was a team effort and consensus was achieved on plan contents? Has the plan been written with enough clarity and detail for any new staff to understand and implement it? If the team suggests many good environmental and teaching strategy changes that will generally benefit the student, consider including these in a separate accommodation plan or a separate list of derived interventions. If the behavior is complex, were strategies used to simplify a complexly written plan? Multiple Behaviors, Same Function If the plan attempts to address multiple behaviors. Consider numbering behaviors with corresponding interventions Multiple Behaviors, Multiple Functions If the plan attempts to address multiple behaviors with multiple functions, writing the plan with clarity and achieving consistent staff implementation becomes extremely difficult. Consider identifying the behavior or behaviors that most interferes with learning and have the same function. Alternatively, consider addressing each selected behavior with each function on separate plans. Underdeveloped plans often contain incomplete or vaguely described interventions sometimes not consistent with the analysis of the problem. Reexamine the function of the behavior Reexamine the match between the developmental level of the student and the interventions. Be sure the team includes all future implementers As you rewrite the plan, consider the quality evaluation guide so that all sections earn the maximum points What if the plan is successful, but scores in the "underdeveloped" range? For example, though a thorough plan includes both teaching a replacement behavior and changing environmental variables, sometimes even partial planning influences behavior. Although the team evaluates the plan as "successful", in the on-going review process which occurs to monitor student achievement of the goals and objectives, the team should determine if changes to the plan are needed to increase the likelihood of maintaining the new replacement behavior or generalizing it to multiple environments as well as decreasing environmental supports (if warranted) because the student has developed new positive behaviors requiring less support. Staff inconsistency in using interventions can also account for the variability of outcomes. Using the guide during the meeting allows anyone playing a consultant or leadership role to focus the team on writing the best plan they can without being the "expert" dictating what should be included. The consultant can engage the entire team in "scoring" what they have written and facilitate a collaborative attempt to rethink and rewrite when inadequacy is discovered. Eventually, teams will be better able to write plans without leadership guidance if they have initial successes and the guide as a reminder of what the plan should embody. A behavior plan will include positive behavioral supports (teaching a replacement behavior, making environmental changes) and effective reactive strategies which include consequences, including punishment and/or disciplinary actions when necessary. By using the guide throughout plan development and review, the appropriate balance between positive behavioral interventions and disciplinary considerations can be achieved. Sometimes the team may have written a lot of extraneous information, making scoring difficult. The team has identified general environmental changes that would benefit the child, curriculum accommodations and remediation plans not relevant to the behavior in question, etc. Ignore extraneous information for the purpose of scoring and search for the information that is to be scored. Establishing the logical relationships between areas to be scored can be difficult, yet this is key to establishing internal validity. Not everything will be so clearly written that you can immediately determine the score especially when interrelating items. Often moving on allows the evaluator to determine overall consistency in addressing the key concepts. Whether the item scores a "1", a partial or incomplete attempt at the key concept, or a "2" will not be as critical as whether the key concept has not been addressed at all, a "0". C-34 Scoring can be time consuming if you use a bottom-up method (looking at "0" and "1" criteria first), and can take much less time with a top-down method (looking at "2" criteria first). If you can tell the key concept is there, even if it could be better phrased, award the score. If you must really stretch to determine the key concept is present, look at the rest of the plan to determine if, as a whole, this plan addresses the strands adequately. Same Function-Multiple Behaviors If the plan attempts to address multiple behaviors. Go through and number the behaviors, then search for the correlate intervention and assign the same number as the behavior. Different Functions-Multiple Behaviors If the plan attempts to address multiple behaviors. The key question is: What method of writing what we intend to do will result in implementers knowing exactly what to do for each behavior? The team may wish to meet again and either: Identify the behavior or behaviors that most interferes with learning and have the same function. Alternatively, consider addressing selected behavior(s) with each corresponding function on separate plans. C-35 Sometimes the plan is for a student who uses one behavior for multiple functions. Applying a strategy to reduce attention seeking or teach attention seeking in an appropriate way does not address a behavior that is being used to protest or escape something, and visa versa. California Department of Education-Diagnostic Centers "Positive Behavior Support" is a conceptual approach that is rapidly changing how we approach problem behavior. By focusing on the following approaches and key concepts, even behaviors that have been occurring for a long time can be changed. These concepts are radically different from reduction approaches that simply try to either punish the student for the behavior, or reward the student if s/he stops the problem behavior. The "Positive Behavior Support" approach is data-driven, based on carefully looking at the context of the behavior to understand why the behavior is occurring. This is followed by implementing an individualized behavior plan, not just to eliminate problem behavior, but to teach the student new skills and change environments and interactions to support a wide range of positive behaviors. The following outline describes what needs to be considered, regardless of the behavior plan format, when developing a behavior plan based on an understanding of the function of the behavior, i. Although all functions are legitimate and desirable, the method or form of the behavior may require alteration. Key Concept: this behavior has worked in the past, or is currently working to either, 1) get something the student desires, or 2) avoid or protest something the student wishes to remove. Requirement: A behavior plan must identify the function of the problem behavior in order to develop a plan that teaches an alternative replacement behavior that serves the same function. Billy throws his work on the floor because it is hard work for him and his face shows anger and frustration. Jane giggles and disrupts peers around her because she enjoys the attention and reactions she gets and her face shows pleasure and excitement. Her actions are to get social attention, even when that attention from peers is one of displeasure and disapproval. Her face shows pleasure and excitement and she uses these words as a method of starting a conversation. Positive Behavioral Support Principle: Behavior is related to the context/environment in which it occurs. Method: Observing the student in the problem situation and interviewing others who are frequently present when the problem occurs is required. Focusing on everything going on around the student, the nature of the instruction, interactions with and around the student, and the work output required by the curriculum is necessary to understand why the student uses this problem behavior. Her peers have not learned how to direct Renee to use the alternative method of attention-seeking rather than correcting her for attempting to get their attention. Positive Behavioral Support Principle: There are two strands to a complete behavior plan. Billy will be taught an acceptable protest for work that appears difficult, such as calling the teacher over and telling her the work appears long and hard (functionally-equivalent alternative behavior). Jane will receive instruction on how to make and keep friends and her peers will receive instruction in how to calmly redirect her to use appropriate interactions to achieve their brief expressions of approval (remove need to get social attention in maladaptive ways). Jane will learn brief interactions during work periods that result in social approval from her peers, yet do not disrupt others (get social attention with functionally-equivalent alternative behavior). Renee will be taught specific social interaction initiation techniques and her peers will be taught how to prompt her to use these techniques (functionally equivalent ways of starting a social dialogue). Reinforcement is actions we take, privileges or tangibles we give, that the student really wants to get, and therefore he/she does the behavior again and again to get that reinforcement. Requirement: the behavior plan must specify reinforcement for the new functionally equivalent behavior. The behavior plan may also wish to specify general reinforcement for positive behaviors as well. Often a general lack of reinforcement available for following class rules will increase a wide range of problem behaviors. When reinforcement is given to all students for a wide range of positive behaviors dramatically decreases in problem behaviors occurs. Diana Browning Wright, Behavior/Discipline Trainings, 2006 C-39 - Method: Find out what the student typically seeks in the environment. Ask the student and observe him/her in the situation or have the student complete a "reinforcement survey" of things s/he would want to earn. Make access to the reinforcer you discover contingent on performing the desired behavior. Jane and her friends will all receive points toward lunch with the teacher for their teamwork and support of each other. The teacher will allow Renee to choose from a menu of tangible and activity reinforcers for every 10 points earned. Key Concept: the behavior plan must specify reactive strategies ranging from: 1) Beginning stage: Prompting the alternative replacement behavior; 2) Midbehavior stage: the problem behavior is fully present and now requires staff to handle the behavior safely through an individualized, careful deescalating of the behavior. This might include specific techniques, calming words, presenting of choices, distraction, and redirection. Some staff deescalate the student better than others and this should be considered. Diana Browning Wright, Behavior/Discipline Trainings, 2006 C-40 - Requirement: All implementers must be clear on specifically how to handle behavior to assure safety of all and that the intervention matches the stage of escalation. Method: the behavior team will need to discuss what has worked in the past to alter the problem behavior, and what interventions are required at all four stages of problem behavior. Beginning behavior Stage: Use gestures Billy has been taught that are cues to Billy to use the alternative protest, i.
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