Each month the staff of Sovia Therapy sponsor a Clinical Exchange aimed at educating providers on various topics of interest.  The minutes from those meetings will be posted in this section.

September 2016: Vision and Visual Strategies in Early Intervention: Cheryl Stewart, TVI. 

VISION AND VISUAL STRATEGIES

Difference between Vision Therapist and Teacher for the Visually Impaired (TVI)  – Vision therapist implies ‘fixing’ of vision.  TVI are trained to go into classrooms and make adaptions for the visually impaired student.  This includes presentation of materials, playgrounds, classroom adaptations.  Many TVI are not interested in working with children that are birth to 3.

Professionals involved:

              Ophthalmologist – medical physician that diagnoses the child, assesses optic nerve.  There are 3 different types – Adult – usually also retinal specialists.  Pediatric – specializes in working with young children (Dr. McMannaway, HMC Physicians, Armesto Eye Assoicates).  Neuro Opthlamalogist – Dr. Soni – he looks at connection between brain and eye.  He is looking for disease in the eye. 

              Optometrist – not a medical doctor.   Did 3 years at optometric school.   Testing for vision, visual acuity.  Not prescribing medicines or surgery.

              Developmental Optometrists  - specialize in vision therapy, functional vision evaluation (much more comprehensive with multi facets . – Dr. Moon – State College, Dr. Septage – Selinsgrove. 

              Vision Therapist – could be the optometrist or someone trained by optometrist.  Working on strabismus (lazy eye), brain injury, convergence, tracking smoothly.  Most of their population is children having difficulty in school specifically with reading.  In order to do therapy, the child must be able to cooperate, so they generally need to be older. 

              Occularist – eye prosthetist.  Very expensive to construct.  Could just have a shell that holds the eye open – so they may have some of the eye left .  Or complete eye to help keep eye open.

              Optician – person that makes the glasses.

              Teacher of the Visually Impaired – education degree

              Orientation and Mobility Instructors – teaching people of the visually impaired how to get around.  Starting children as soon as they can creep on hands and knees.  Relatively new field for vision. 

              Transcription specialist – specialized schools for the blind turning books into braille.  Computerized now with an embosser.  The transcriptionist proofs the book and makes sure it is correct.  Seedlings.org and APH (American Printing House for the Blind) provide books.  The Federal Government provides what children need (quota money) so they can participate in education.  Anything mailed for the blind is free. 

              Rehabilitation Teacher – teaches someone that is newly blinded how to get around. 

              Low vision specialist – looks at equipment to see if adaptions would help

              Equipment vendor – equipment to help with magnification and braille.

School based services go until the child is 21.  TVI are doing expanded core curriculum – daily living skills, recreational skills.   It used to be that if you were blind, you were educated at a school for the blind.  If you had another disability you were not accepted. 

Vision development as it relates to cognitive skills:  (1) awareness of environment (2) attention to the environment (3) understanding of the environment.

Babies are first attracted to light, then people.  Most see 6-8” in the beginning.  Last is objects.  See best near (arms reach), then further away.  First interested in peripheral vision, then central vision.  Will look at things that are familiar first before things that are new.  Will also look at parts of things before the whole thing.  Simple shapes to complex and large to small objects. 

Early Intervention didn’t always have visual services.  In the 80’s, schools started to service children at age 2.  We now know that the younger the better.  Most services are largely not provided by the IU. (some local areas do – CMSU, York, Lancaster)

Parents feel the diagnosis of blindness is devastating and they go through the grieving process as if the child has died.  TVI help families understand and stop being afraid of the diagnosis.  Education is key.    Talk about how the rest of the family feels – grieving for the family and child and what they will never be able to do.  Emphasize treating the child like a typical child and have them experience as much as possible.  We learn from incidental learning. 

Diagnoses seen – Cortical Visual Impairment (biggest diagnosis right now).  Eyes are fine, brain does not recognize signals.  We can help kids to see better – help to ‘cure’ the issue.  This is the child who looks right through you, or looks at the ceiling fan, waves hand in front of face, only picks up red toys, stims from anything shiny, or acts totally blind.  “Look, look away, look” – need to look away to play with the toy.  Does not necessarily need to be a child with other diagnosis.  Optic Nerve Hyperpalsia – small underdeveloped optic nerve.  Sometimes need growth hormone, sensory issues, eating disorders.  Not really a vision disorder – actually a brain disorder.  Albinism – two kinds – can be completely involved with hair and eyes or just pale eyes.  Congenital cataracts – can have as a child.   Nystagmus – eye shaking that can come from all kinds of vision loss.  The room isn’t shaking, just blurred.  Strabismus – eye muscle disease with combination of eye turning.

Not keeping patch or glasses on is not a vision issue -it’s behavioral. 

Always tell child what you are doing.  Use tapping or rubbing to let them know you are picking them up.  Tell the child when you come in/out of the room. Tell them what you are doing.  Keep things simple with good contrast.  Use black or white background.  Lighting/glare – light should come from behind child and onto thing the child is playing with.  Watch for squinting and not responding based on lighting.  Bigger pictures might not be better – smaller might be easier to see. 

Medication Assisted Treatment and Recovery Support

Kristin Varner, RASE Project

Outlined RASE Project services.  www.raseproject.org  100 North Cameron Street, Suite 401E, Harrisburg, PA 17101.  717.232.8535.

We started with addiction:   Addiction is a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use despite harmful consequences.  (National Institute on Drug Abuse).  This is not a moral failing, but an organ system failure.  PA is  #1 for male opioid overdose and #7 for deaths overall.  Your body does not know the difference between medical pain management or heroin.  Over prescribing of medications led to heroin when people could not get more prescription drugs. 

Disease is defined by disease classification: pattern of symptoms, chronic, progressive, subject to relapse, and treatable.  It is not curable.  When you have the disease of addiction, if you engage in behaviors that are conducive to the disease, you will relapse.  Must change lifestyle to recover.  Other lifestyle diseases are diabetes, heart disease, asthma, etc. 

Addiction has biological and non biological factors.  Addiction is 50% genetic.  Females use early and at quicker rates than males.  If someone in your family suffers from addiction (any kind – shopping, food, gambling) you are 90% likely to carry on that genetic predisposition.  Many people in recovery will have symptoms of mental illness.  Individuals in early recovery have extreme anxiety.  These individuals are used to doing everything with a chemical in your system.  Supportive services help them thru the process without adding another drug in the system.

Non biological issues include cultural and social values, developmental variations, personality difference, abuse, trauma, parent use and attitudes, community/social attitude, and perception. 

Substances with the potential for addiction affect dopamine levels in the brain.  Initially, a person takes a drug to change their mood, perception or emotional state but in reality they are changing their brain.  People with a substance abuse disorder have less dopamine then others.  Less ability to feel good or feel happiness.  When they start using drugs, the drug releases dopamine and they feel better.  The drug of use becomes the key to life.  After flooding their brain with dopamine, they have no dopamine left.  It takes 1 year to 18 months to restore the dopamine that was used.  Our insurance companies authorize 7 days to 2 weeks to 30 days of rehab.  The brain needs more time to heal. 

Historically, there have been ‘miracle’ cures for alcoholism and addiction.  Examples included Dovers Powder, Laundanum, Godfreys Cordial, McMunns Elixar, Mother Bailey’s Quieting Syrup (this was morphine to stop babies from crying.  Many died from overdose).  Many of these products contained high level of substances that addicted folks. 

Medication Assisted Recovery with medication assisted treatment.  This refers to treatment for a substance use disorder that includes a pharmacologic intervention as part of a comprehensive substance use disorder plan with an ultimate goal of patient recover with full social function.  The hopes of the program are to improve survival, increase retention to treatment, decrease illicit opiate use, decrease hepatitis and HIV, decrease criminal activities, increase employment and improve birth outcomes. Withdrawal stabilization is the start of recovery.  If the brain receptor is not filled with the opiate, the individual goes through withdrawal.  Feels like the flu x100.  Individuals suffering from addiction end up relapsing to complete routines.  80% of opiate users start with a prescription pain medication.  Opiate addicts do not like pain and fear pain.  Individuals will not die from just going through opiate withdrawal.  Alcohol and benzodiazepines need a medical withdrawal management (Naltrexone, disulfiram, acamprasate calcium – takes away cravings for alcohol ).  There is a huge environmental piece that goes with addiction.  There have been babies born addicted that do not grow up to become drug addicts.  So our babies that are on wean down protocols from pain management need support environmentally.  Coping skills are lacking with individuals that suffer from addiction. 

Vivitrol – injection – long lasting means of controlling cravings and controls relapses.  If also on suboxone or methadone.  Costs about $1200/month for the injection.  Decreases cravings for alcohol.  When medication wears off, the cravings come back and then the individual overdoses. 

Disulfiram – only a deterrent.  Interferes with metabolism in the brain.

Acamprosate Calcium – speeds brain recovery process by reducing risk of relapse. 

Toprimiate – anticonvulsant, mood stabilizing medication.  Not yet approved by the FDA for addiction.

New medications: Zofran, Serzone, Lioresal (baclofen) .  May reduce alcohol cravings and intakes.

Opiod Medicaions: Methadone (clinic) – synthetic opioid blocks effects of heroin and other prescription drugs containing opiates.  Liquid form out of a methadone clinic.  Individual needs to go everyday for medication.   As individuals do well in treatment, they can have a take home medication.  Methadone is a full opiate that is a substitute for the opiate.  Counseling is required with drug screenings.  Very difficult to come off of – hardest to detox from. Very long half life – stays in body for months.  Boiling Green or Valley Forge detox centers.  Keep dose as low as possible for eventually getting off of methadone.  When you wean off methadone, that’s when the most intensive treatment starts.  Recovery plan to come off of methadone is not as successful.    Plan is keep them on methadone and safe.  Methadone causes cavities, constipation, and brittle bones. Methadone is cheaper (.30/dose).  Families that have not taken their methadone for the day will appear impaired.  There is an option to refer the individual to a Recovery Specialist through the RASE project. Services are free.   They can connect them to the social service pieces.  They are required to go to counseling. 

Any type of medication for addiction will not change anything unless you change your lifestyle. 

Suboxone – buprenorphine – synthetic opioid described as a mixed opiod agonist-antagonist.  Brain healing can start on suboxone.  Buprenorphine attaches to brain receptors and locks them so the individual no longer needs the opioid. If the individual uses during this process, the body goes into precipitated withdrawal (worse withdrawal ever).  Must be taken every day at the same time.  There is a 13 month wean off protocol.  Suboxone does have a street value because it has a euphoria the first few days before hitting a ceiling.  Any program that deals with suboxone is highly monitored.  Have to be evaluated for the program.  Must be addicted to opiates, come to counseling, recovery support, film count (count medication that are supposed to have), drug testing.   Women with babies on saboxone have minimal withdrawal symptoms than methadone.  Subutex is similar but may be prescribed for pregnant women.  Physician’s must go through a course to be able to prescribe saboxone. 

Vivitrol – non addictive, no opiates and blocks opiates.  Can be used for opiates or alcohol.  Monthly injections $1200/month.  Blocks cravings.  Injections covered by a grant as long as they participate in the program. 

Rationales to not enter recovery: limited options, stigma, recovery setting have been highly structured and providers had subscribed to an abstinence based model.  Individuals can get into recovery and stay clean without medications through the use of recovery support.

During every day, individuals are working in either a relapse or recovery process.  Good retention would include people being in work, clean while in treatment and strong support systems. 

Narcane – available at any pharmacy.  It has been around for years.  The prescription was written by the state.  If someone has overdose, you can inject with narcane.  It reverses the effects of the overdose until they can get in to the 911 system.  It does not work on just anything.  Recovery specialists meet the person on scene at the hospital and stay with them until a recovery bed is available in rehab.  (Warm Hand Off – York, Adams and Lancaster).   We can refer to recovery specialists in Dauphin, Cumberland, Perry, Lebanon, Lancaster Counties.   

Sensory Processing and Eating Issues in Children with Autism

The Seven Senses of the Body

• Sight

• Smell

• Taste

• Hearing

• Touch

• Vestibular (perception of our body in relation to gravity, movement, balance; spinning, jumping, swinging)

• Proprioception (sense of body position in space and strength of effort needed for movement)

Responses to Sensory Input: Hyporesponsivity – takes more than average sensory input to get a response OR Hyperresponsivity – takes less than average to get a response to sensory input

Early signs of sensory issues include problems with:

• Sleep

• Eating

• Self-Care/ADLs

• Motor development

• Bonding and connection

• Social Participation

• Behavior/Regulation

Sensory Processing Disorder – Condition that exists when sensory signals don’t get organized into appropriate responses. It is a neurological “traffic jam” that prevents certain parts of the brain from receiving the information needed to interpret sensory information correctly.

Sensory Processing Disorder (SPD) is different from Autism (ASD). SPD is just one characteristic of Autism. Just because a child has SPD it does not mean they have ASD.

Low sensory registration – notice sensory stimuli much less than others, may seem uninterested, self-absorbed or dull affect, miss cues that might guide behavior, interventions are directed at increasing the intensity of sensory input.  

Sensation Seeking – enjoy and generate extra sensory input, very active, continuously engaging and excitable, becomes a problem when seeking behaviors keeping the person from continuing in a necessary activity.

Sensation Avoiding – Bothered by input more than others. Tend to be rule-bound. Ritual driven and “uncooperative”

Sensory Sensitivity – detect more input than others, distractible, hyperactive and can be “complainers”, notice more sensory events than others do.

Feeding

What does it entail? It is complex occupation requiring oral motor, fine motor, sensory processing and social communication issues.

Mealtimes help delineate time in a day, provide an opportunity for family members to bond, learn to communicate and share and practice cultural routines.

Considerations that influence mealtime: Family composition, cultural beliefs/values, personal factors.

Feeding issues and Autism

Factors that impact eating: Sensory issues, behavioral issues, medical issues, attention issues, language/social issues

Oral sensitivity – resistive to textures in and around the mouth, child may not put toys or other objects in mouth, child may gag or even vomit with new textures. Have difficulty with face washing, nose wiping, teeth brushing

Tactile Defensiveness – Try exploring textures outside of mealtimes, show child that textures can be cleaned off, Use of utensils to keep the hands clean, provide napkin or wet cloth during mealtimes to wipe hands.

Food selectivity – diets tend to be high in carbohydrates and low in fiver and protein, often prefer processed foods because they are more consistent in flavor expectation, preferences can be highly specific including brand.

Trying new foods:

Offering non-preferred food with preferred food at same seating, tolerating the food being on the same plate regardless of whether they try it, use of visual reward system, modeling from siblings or peers.

Food Chaining – builds on successful eating experiences, foods that a child accepts are studied for patterns in taste texture and temperature. New foods similar to the ones the child eats well. Expanding while maintain texture and flavor (trying different brand of chicken nugget), Vary taste while maintaining texture, vary texture while maintaining taste, vary taste and texture.

Medical issues: Constipation and allergies

Constipation x4 more likely in children with ASD and related to diet issues. Depending on fother factors may benefit from infant massage for stomach discomfort/constipation, we can support families in talking to their pediatrician or specialist about these problems

We do not want to try to offer suggestions without medical supervision: Miralax, Pediasure, other supplements

Attention

Child has difficulty sitting in chair for meals, child would prefer to graze, eating for short periods of time, eating and playing at the same time, decreases social demands as well, Provide sensory diet activities before mealtimes, exploring seating options (high chair, booster, child sized table), use of time or simply limiting mealtimes to an achievable length, use of plates, utensils with preferred characters.

Communication

Child not able to express hunger or thirst – constant access to food and drink which decreases child’s need to communicate or interact with family, child will have tantrum with new foods are presented

Social interactions

Child is not comfortable making social contact with others to get needs met, child does not like to sit with attention focused on them during mealtime, child has a difficult time sitting among family members, making eye contact.

Self- Feeding

Use thinker textures with stick to spoon better (yogurt, applesauce) , Set up bites on fork to practice taking to mouth, practice utensil use outside of mealtime (scooping in bean box, pretending to feed stuffed animals, using fork with playdoh)

Helping Parents Accept their Child's Diagnosis and The Grief/Loss Process

Laura Bosley, LSW

Aspirations, LLC

Helping Caregivers and Parents through the Diagnosis Process

As professionals we need to be sensitive to parents and what they’ve been told by professionals.

• Example: “your child will never walk, talk, or communicate”, “he/she will not live past their first birthday”

Parents can respond positively or negatively to their child being diagnosed. There are multiple factors impacting caregivers’ response to diagnosis:

• Specificity of disability

• Length of diagnosis process

• Parent expectations

• Family dynamics

• Parent mental health

• Our societal views on children with special needs

Diagnosis process: Many view the beginning of the process as a time where the concerns about the child’s health are expressed, evaluations are made.

Why is a diagnosis important to a family?

• Holds the key to funding.

• Knowledge, can provide a course of action.

• Can provide a prognosis.

• Can help with a network of support.

Positive growth of a child depends on how the family reacts to the diagnosis of a disability in their child.

How parents perceive the diagnosis process: It’s emotionally- laden, in the time which the parent redefines themselves as parents.

Professionals hold the knowledge and can be confusing. They can be judgmental.

What can we do to improve the diagnosis process and family understanding?

• We should ask the parents what their learning style is.

• How much and why types of communication they find helpful

• Build rapport with honesty and caring.

• Encourage parents to ask questions.

• Teach parents to advocate for themselves.

• Important to know the resources

• Readily admit to unknowns and seek answers.

How can EI providers collaborate to be more sensitive to parents during the diagnosis process?

• Normalize feelings, allow parents to express feelings in their own way. Parents may not be on the same page.

GRIEF

Elisabeth Kubler-Ross On Death and Dying (1869)
Stages of grief: Denial, anger, bargaining, depression, acceptance No one person goes through all these stages in the same way. It doesn’t necessarily happen in this particular order. It is import to help families normalize their feelings. Possible feelings of anxiety, fear, powerlessness, guilt, confusion, sadness, envy, disappointment, rejection, mistrust, uncertainty.

If a parent has lost a loved one you can ask them “Tell me about your child, mother, brother… ect.”

Coping skills – take care of themselves so they can be there for their child,

Additional help for parents -

• Parent support groups

• Rely on positive sources in your life

• Learn the terminology

• Seek information

• Do not be afraid to show emotion

• Coping strategies

• Do not be intimidated by medical professionals

• Take one day at a time

• Encourage parents to talk with family, spouse and significant others

• Help them not be afraid of medical professionals

Greif resources

Tear Soup: A Recipe for Healing After Loss - Book by Chuck DeKlyen and Pat Schwiebert

When Bad Things Happen To Good People – When Bad Things Happen to Good People - By: Harold S. Kushner

Option B – Option B: Facing Adversity, Building Resilience, and Finding Joy – By: Sheryl Sandberg, Adam Grant

Stabbed in the heart –

Stabbed in the Heart: Three Murdered Children Two Resilient Mothers - By: Lynn Shiner (Author),    Nancy Chavez (Author), Nancy Eshelman (Author)

DENIAL

Use of term “in denial” in labeling parents of children with disability stems from Kubler-Ross’s work on death and dying

Denial can sometimes be useful to some parents during the grieving process.

The term can sometimes be used in a judgmental way by professionals toward parents.

Professionals who categorize parents as “in denial” unaccepting, or difficult, lose the chance to understand and learn from them.

It may be helpful to rephrase the term “in denial” to “in hope”

It is important to be honest and hopeful.

We cannot diagnose but it is our ethical responsibility to point out things to families that we are seeing.

Challenging Parent Behaviors: Clinical Exchange with Bridgette Vogelsong, SI and Teresa Jones, SLP

1. How do you get parents to reflect back to you? 

“Show me” what it is you can do.  Reflect back on what you worked on last visit and ask questions about showing you what you can do next.  Language barriers can be difficult and may be difficult  - ask how that fits into their routines.  Very difficult to be engaged as a parent when there is little change week to week. 

2. When the parent is relaying information to you and they have an inaccurate assessment of the situation, how do you reflect/redirect without offending them and continue to build trust?

Ask for an example of when the behavior happens with that child. Show me what he is doing.  Families will have barriers for the reporting.  Cross check facts and help to shape the correct story.  Be careful not to lose the family member – because child could be able to respond to the family best.   Cross check when they are demonstrating the skill.  Could use a skill list for other settings so everyone knows what the child is doing.

3. Dual language households with red flags for ASD are difficult to tease out.  Families tend to blame it on learning two languages.  Go back to symptoms and see what the family thinks is normal.  Education on what autism is and what the flags are.  Need to be sensitive and aware of the family’s culture and cultural expectations. 

4. Watch comments like ‘you are the expert what do you think’.  Does that mean they don’t want to work on that skill or that skill isn’t important.  Ask what is working well and what is not working well.

5.  How to set up ‘good families’ – ask questions to see how family is doing.  Building relationships with families early. 

6. Behavioral strategies are difficult to implement and change.  Shared handout about adult learning.  Adults enjoy learning opportunities and that will be appealing, adults learn best when expectations are clear, habits and beliefs take time to change, learning is best when it fits into established patterns of interaction, adults learn systematically and sequentially, adults tend to teach others the way they like to be taught,  and active learning opportunities increase adult participation.

7. Discussions about autism or social differences.  Should not be happening at annual evaluations but does happen at initial evaluations.  Use the MCHAT to help guide conversations.  Family is in denial (maybe the right term is ‘not ready’).  Guide to another place for help in the diagnosis.    Dr. Stranko (Pinnacle Health/UPMC Infant Development Program – approx. 4 months); Dr. Tiernany (HMC – 1 year wait time); Dr. Ramer (HMC – 1 year wait); Philhaven Lancaster (Center for Autism and Developmental Delays – has a fast track program and they do take MA); Geisinger Medical Center (Center at Bucknell);  Lancaster (Dr. Carey – New Day Psychological Services).  Check ASERT website as a resource center for autism.

8. When talking with parents, we like to incorporate strengths and specifics about the child so the parent understands what needs remediated.  Give a case study of how this worked well, and one where it didn’t go so well and how you made it work. 

‘Catch them being good’ – better positive reinforcement vs negative reinforcement.  Immediately reward the positive behavior.  Helps to build the family’s capacity for implementing strategies.  Parent/caregiver praise is important to give.  Talk about their child’s strengths

9. Engaging parents who are on their phone or who have the TV on an adult show.  Ask parent to bring back something to engage the child (cotton balls, newspaper, qtips).  Use low tech (play from recyclables).   “Let’s see if they can pay attention better with the TV off vs on”. 

10. We know that children that do not have a caring attentive parent could be at risk for attachment issues.  How do you facilitate attachment in your day to day therapy sessions? 

Set routines at home (provide structure) and limits.  Don’t break routines. Give activity ideas (tickle time, cuddle time, bedtime story).  If they wake in the middle of the night it’s ‘business only’ -diaper change, food.  No cuddling.  With children that have addicted parents, (methadone) what do services look like?  Tracking?  Check sensory strategies (bouncing, vibration, tickles) to gain attachment.

11. C2P2 parent training is worthwhile to recommend to empower parents.  They help with legislature and understanding laws.  Need to be involved with state wide training and involvement.

12. Sometimes we are the first or second person to point out a delay or difference with the child.  How do you facilitate that conversation?  Or if you are the second/third therapist from a case where others have been replaced/fired?

Tease through what might be the reason for the obstruction.  Look at the child in a broad sense – communicate with the other therapist on the team and see how they are handling the issue.  Sometimes difficult when the team does not get together often.  Best to discuss 1:1 first rather than in a team meeting. 

Cultural differences?  Indian culture appears to be high incidence?  Is it their culture?

Creepy Crawlers: Bugs You Don’t Want Biting You!

Dion Lerman, MPH, ACE

PA Integrated Pest Management Program

There are free tenant rights services in almost every location. 

Integrated Pest Management is about getting the pest under control and the prevention of the pest from multiplying.  Many pests have become resistant to pesticides.  The control also has to be safe for people.  Pesticides are the last tool used – but when used, they use high concentration of pesticides with high toxicity.  They should never be used around children. Chemicals need to be used in the safest place by a licensed pesticide applicator.  Thinking of integrated pest management as a pyramid.  Use a HEPA vacuum to suck up bugs. 

Pests need food, shelter, a place to hide/move and the ability to reproduce.  Very important to have positive identification of the pest first.  Also need to know how the pest invades home/school.

Fleas: Female lays eggs after each blood meal (after a bite) – lays up to 400 over a lifetime.  Hatch quickly – one day to a week.  Eggs are not sticky and will fall into cracks.  Fall off a pet and into carpet and then hatch.  Don’t need to fog the ceiling. They can remain dormant for up to a year and will trigger by vibration.  Fleas can cause mosquito like bites – more irritation and a nuisance.  Plague is carried by fleas.  Common remedy is to fog the space, but we then are exposed to pesticide. Very risky and not that effective.   How to treat for fleas: clean bedding, etc, vacuum areas daily for 3 weeks and use a trigger spray that has two components – adulticide (non-pyrethroid; -thrin ie fibronil) and IGR (insect growth regulator – methoprene).  Heat kills all bugs at all stages including the eggs!  To monitor for fleas, could see with a green light or sticky trap

A hot dryer for 30 minutes kills all bugs (no need to wash first).

Head Lice: only live in hair (not body) usually towards the back of the scalp.  Feed on blood – glue egg (nit) to the base of the hair shaft. Eggs can last up to 2 weeks.  Can live as long as 30 days.  Stay on the head.  If they fall off, they die quickly (24-36 hours).  They can’t jump, fly or burrow.  Anybody can get lice – does not relate to personal sanitation.  Head lice do not transmit diseases, but they cause itching, or sores on scalp.   Mechanical remover is best or heat (over 120degrees for 30 min).  Combing with a fine toothed metal comb to remove lice and nits.  Conditioners can help (cetaphil  wash– nuvo or oils) suffocate the lice and eggs.  Prescription shampoos contain nerve poisons and are not recommended.  Lice have developed a resistance to pesticide shampoos.  Essential oils can be effective (melaluca – tea tree oil) but can be very dangerous to young children.    

Ticks: many different kinds.  Two discussed – blacklegged ticks or deer tick (white legged tick).  They have a 1 ½ life cycle.  White footed mice pass the white legged ticks to humans.  In order to have White Nile Virus, must bite someone that has the virus.  The larva feed once and nymphs feed once each stage.  Adult ticks move back to deer and other large mammals.  Will get ticks from being outside.  They climb and put pinchers out and wait for a host.  Ticks are the second greater vector of disease against humans.  Lyme disease – 40% of our ticks are infested with Lyme disease.  Takes 24 hours to infest.  Post treatment Lyme Disease Syndrome – did not respond to treatment.  Avoid ticks is the best prevention.  Light colors, long sleeves and pants, DEET 10-30% (higher concentrations are not more effective) – not for children under 6 months.  Put on clothing rather than skin under 6 years old, wear a hat, picaridin, oil of lemon eucalyptus (children over 3).  Don’t wear pesticide treated clothing.  To remove ticks: grasp above the belly with tweezers and pull straight up.  If the head remains, pull out with tweezers.  If you save it, put in alcohol.   To control ticks, reduce vegetation near people areas, tick tubes (mouse rubs in tube and takes back to nest to kill ticks)- creating a barrier between you and woodland.

Scabies: lives inside human.  Tunnel under skin with females laying eggs as they tunnel.  Diagnose with skin scraping – can see under a microscope.  Commonly chest, buttocks, abdomen, wrists.  Insist on proper diagnosis (with microscope) before treatment.  Get scabies with close personal contact (child care, camps, sexual contact, rarely from a fomite (inanimate object)).  Pets can be infected (mange) but cannot be transmitted to humans.  Treatment – wash clothes, bedding, prescription cream (permethrin cream) applied to entire body from neck to soles of feet and repeat a week later.  Can use antihistamines for irritation.  Ivermectin can be used but NEVER with children.

Bedbugs: Very important to correctly identify the bug.  Eggs and bugs can be anywhere where a credit card can fit.  Eggs hatch in 6-10 days. Can only survive if they get blood to grow.  They shed their exoskeleton to grow. At each stage, they need a blood meal before they can molt.  Eggs are highly pesticide resistant.  Can spray the eggs and they will still hatch. When bites appear – most likely had bedbugs for 6 months beforehand. Cannot fly, jump or burrow.  They walk very well.  They can live without food for 4 months.  Best treatment is hot dryer after being washed for 30minutes.  Attracted to body heat, and CO2, and body odor.  They are attracted to dirty clothes.  Recommend dirty clothes be kept in a ziplock bag and then washed.  After the female has mated, she leaves to find a spot with no other bedbugs to lay eggs.  Primarily travel by hitchhiking – cling to clothes, crawl to next host.  Can be on furniture, clock radios, etc.   Get bedbugs because we are unlucky – not because dirty.  Will transfer where people sit for a period of time.   Bedbugs live in mattress, boxspring, headboard, baseboard, lights near bed.  Will spread over time to bedside furniture and closets. Will eventually be everywhere in the house/apartment.  Can move through electrical wires, plumbing and throughout the walls. Bedbugs have not been shown to spread disease yet.  They have the mechanism to spread disease..and secondary infection is a factor.    Denying service based on bedbugs may be a violation of ADA – wear simple clothes, wear booties, spray ankles with DEET (will not keep bedbugs away, no bedbug will come near you), do not sit on couch or upholstered furniture, nothing on anyone’s bed.  Discard booties when leave and can put clothes into ziplock until get to a dryer.  Could have a fear that you have bedbugs but you don’t.  80% of samples sent to be tested contain no bugs.  Bites themselves are not diagnostic.  Some people never react to the bites and the older you are the less you will react to the bites.  Characteristic  to have bites in a row because bugs line up to bite.  What to do? Start with education and discuss what they are.  Encourage to report as soon as they see them.  Basic identification of the bug.  Look for staining, groups of bedbugs, etc. Install interceptors under legs of furniture to collect bugs. 2 weeks later – if you have bugs in the interceptors, encase mattress and boxspring with cover so bugs can’t get out.  Vacuum and steam and maybe pesticide.  Cimexa will kill bedbugs  in cracks, crevice, electrical outlets, and surfaces.  Check again in 14days and up to 6 weeks because eggs hatch.  Should include 3 visits at 10-14 day intervals.  At least a month of infestation when you start treatment.  Penn State has developed a biopesticide (Aprehend) and kills an individual bug in 4 days and then goes on to kill colony.  Just available since November so waiting to see how it works. 

Effective Treatment Strategies for Infants and Toddlers with Hearing Loss

Michelle Campbell, Teacher for the Hearing Impaired

Jessica Marks, MA, NIC

See PowerPoint for bulk of notes. 

Insurance dictates that children must be a minimum of 12 months old for cochlear implantation.  If the family is private pay, implantation can be done as young as 9 months.  Prior to that time, the infant’s head is changing too much for implantation to be done successfully. 

See hearing loss guidelines.  Exception is progressive hearing loss or if allergic to hearing aids.

More severe hearing losses can’t hear speech sounds at all.  Cochlear implants bring hearing back to mild loss or normal. In order to implant a cochlear implant, must have an intact auditory nerve.

When working with children with hearing loss, embed into routines all teaching strategies to link sign to task. 

When children are activated with their cochlear implants, the activation date is the child’s ‘hearing birthday’.    The task becomes to attach meaning to sound. 

A BAHA is a way to bypass the ear with a bone conduction device – typically used for older children.

Book reference – Rebuilt by Michael Chorost – adult with cochlear impants.

Literacy is extremely different for children with hearing loss.  Need to take a child that signs and teach them English.  No sign for ‘a’, ‘the’, ‘and’, etc….

The School for the Deaf – located in Pittsburgh.  180 children  that all communicate via sign.  Ages infant – 21.  50% of the students are residential.  23 students are bused there from this area and meet on Fridays to come home for the weekend and then return to school Sunday afternoon.

Scranton School for the Deaf – infant to 8^th grade.  Previously this school was run by the state.

Choices for Children – Early Intervention Services including preschool (now have 14 children) in Hershey (Fishburn United Methodist Church), teach sign language (currently Tuesday evenings with a new class beginning April 9^th). 

Referenced Hands and Voices Face Book Page as a resource

Wegmans offers a Deaf/Hard of Hearing social the first Friday of each month.

The Use of Essential Oils in Our Modern World

Presented by Beth Davis, RN

• Prevention is the key with essential oil.Our modern medicine is about treating symptoms.

• Essential oils are volatile liquid found in plants that can support every system of our body.

• How to use them?Aroma, thru skin, ingesting

• Purity is very important – know where it came from.Only need 5% true essential oil to claim to be therapeutic grade.Young Living is compliant with FDA

• Lifestyle change to switch out chemical products with pure products.

• Carrier oils help to take the oil deeper

• Safety- some oils are photosensitive (lemon, grapefruit).Some are hot (dilute them to a comfort level - oregano).Do not apply oils near on in your eyes.Dilute oils for babies and children.If using Young Living – look for white label for ingesting.

• Misconception is that you have to use one or the other – use what is best for your body.

• Carrier Oils (olive oil, coconut oil, jojoba oil, almond oil, grapeseed oil, V6). – dilutes the oil and allows the oil to be moved around.It stretches the essential oil further too.Provides ease of application.If you have a reaction to an oil, then use an oil to stop the reaction.

• Lavender:calming, relaxing and good for skin.

• Frankincense: calming, grounding, good for skin, look up studies on treatment for diseases

• Citrus Fresh: citrus, diffusing – makes house smell clean and fresh, cleaning supplies

• Peace and Calming: calming,nighttime relaxing

• Valor: confidence oil, add to shampoo to help with color (blue tansy,

• DiGiz: stomach upset, add peppermint to this one for better smell – if skin is sensitive, then dilute down

• Raven: chest congestion, expand breathing

• Stress Away: reduce stress

• Thieves: aid in immunity, help with illness

• Panaway:pain management

• Peppermint: can use in cooking, uplifting, cooling, up/down spine to help with fever

• Lemon Oil: can make Clorox, baking soda with lemon, takes off sticker residue, detoxifying for liver, diffuser.Seasonal allergy mix: lavender, lemon and peppermint

• Why consider alternative therapies?To lower toxic load – decrease chemical build up.Anything you put in or on your body goes into your system.Highest chemical oils are in bathroom, kitchen and laundry room.Switch and ditch products that contain chemicals for natural items.

• Prevention: aid body in natural wellness.Modern medicine focuses on treatment of symptoms.

• Fragrances are the most toxic items – and contain chemicals.

• Savvy minerals is the make up line that contains no chemicals.

• Us as Caregivers – increases immunity, aid in wellness and optimal health, stress relief.Liver and kidneys need to detox everything you put in and on your body

• Fabreeze – witch hazel/water and essential oil of choice

• If drinking an essential oil- use glass or stainless steel

• If heating a food – don’t use plastic – you are heating the chemicals too.

• Sunscreens need to be reef safe.Lavender and a carrier oil help with burns

ATTACHMENT

RACHEL BECHTEL

Attachment Theory – psychological  theory – ability for an infant to form an emotional and physical bond to a caregiver. 

Well run orphanages had significant issues with attachment even though physical needs were met.  Children had difficulty with relationships later.

Core concepts  - early environments mater.  Human relationships are the building blocks of development.  The course of development can be altered in early childhood by effective interventions that change the balance between risk and protection. 

Biology wires the brain, but the brain is flexible.  Groundwork is laid in the early first years.  Positive early experiences are essential to healthy development in children.

Healthy early social emotional skills are essential for all other learning.

Most brain development is in the first 7 years with the most happening in the first 3 years.

Stress is inevitable with children.  It becomes toxic if the child is in constant stress filled environments. 

Attachement is an innate drive to survive.  We are dependent on an adult/caregiver to survive.  We need caregivers to reduce discomfort. 

Normal cycle – infant feels a need, and responds.  Response is responded to.  Infant has relief. 

If disordered – infant expresses need and there is no response.  Or the response is punitive .  50-60% has secure attachment. 

Anxious-Avoidant Attachment: 20% of the population – child shuts off distress, avoids contact or interaction with caregiver.  Aloof, distant

Anxious-Resistant Attachment: 10-15% of general population – highly distressed by separation, fearful of exploring, whiny, clingy, demanding, angry.  Parent is inconsistent

Disorganized Attachment: 5-10% of population but those that are 80-85% maltreated.  Child is erratic – contradictory, or confused response to caregiver, manipulative

Attachment and Pervasive Neglect: chronic institutionalized and/or neglect  with multiple placements and persistent disruptions.  This could be multiple foster homes. 

The only thing a child has is the caregiver taking care of them.

Exposure to violence – child will have increased cortisol levels in the brain (stress hormone).  Develops a fight or flight response.  

The biological impact is huge- children exposed to chronic stress or suppressed brain development early are at higher risk for cancers and long term aversive conditions. 

Talked about the ACE Questionnaire (Adverse Childhood Experience Questionnaire) and how that score can impact future development.  Each item has a score of 1.  67% have  a score of 1 on ACE; 12.6% have 4+ (at risk for higher rate of suicide or COPD), 7+ have triple risk of lung cancer or heart disease. 

Cognitive impact of poor attachment:  lower IQ, poor school performance, rigid limited problem solving, math and reading deficits, lower standardized scores, receptive/expressive language delays, poor concentration and memory deficits. 

Reactive Attachment Disorder: RAD – will have difficulty for the rest of their life.  Usually from multiple placements and abuse.  Maternal postpartum depression, parental mental illness, substance abuse of parent, inexperienced parent.  Treatment – focus on reinforcing attachment.  Parent/child interaction therapy is helpful for RAD. 

Postpartum depression: mood disorder that affects mothers after childbirth.  Severe depression.  Does not have a single cause, but is a combination of hormones and after giving birth.  Normal to have baby blues for a week or so after giving birth- 80% of new mothers and then goes away..  Not normal to have a pervasive issue.  Feeling sad, hopeless, empty overwhelmed.  Thinking about harming self or the baby.  Avoiding friends or family.  Persistent doubt  about ability to care for the baby.  OB  and Pediatrician’s are screening.  Look for free screeners for post partum depression.  Biggest risk for depression – poverty, previous depression prior to giving birth, stressful life event, medical complications, alcohol/drug abuse, or mixed feelings during pregnancy.  Can affect anyone.  Treatment – counseling/therapy or medication.  If not treated  - depression can g on for months/years.  Interferes with ability to connect with the baby.

Resilience  - the individual is able to rise from early experiences. 

Empower parents – instill confidence.  Increase competence and confidence.  Notice how the child responds to caregiver.  Tell them what they do well.  Help them to identify strengths.  Warm, responsive and nurturing is the way to instill bonding and attachment.  Educate caregivers on attachment and bonding.

Parenting principles:  discipling to facilitate trust and safety.  Collaborate with professionals and engaging in treatment approaches.  Acknowledge expression of feelings and let child know how much you care.  If going between households – provide clear expectations for visitations and moves.  Read cues of child to build trust.  Accept regression and allow mingling of scents between households and caregivers.  Create low stress environment – routines are key. 

NAS – babies look good at least very young.  Concern is mom that is also addicted. 

For Parents on Attachment

https://www.youtube.com/watch?v=TI-BXTHvRfs

Regulation Hand Model Example

https://www.youtube.com/watch?v=gm9CIJ74Oxw

Still Face Experiment

https://www.youtube.com/watch?v=apzXGEbZht0

Child Neuroscience on attachment in a few minutes:

http://www.youtube.com/watch?v=tLiP4b-TPCA

Marijuana and Medicine
 

• Hybrids have been created to increase THC
• Cultivated for centuries for hemp fiber, medicinal/psychoactive properties (THC-tetrahydrocannabinol) is the active component)
• The plant itself contains 460 compounds.  At least 80 are considered cannabinoids.
• A cannabinoid may be psychotropic but can actually be a plant based synthetic or endogenous (made in our body).  Present in leaves, flowers, stalks and seeds.  Leaves and stems contain the most THC (3-22%).
• Our bodies have ready made receptors for marijuana
• Phytocannabinoids – plant based cannabinoids. 
• CBD and THC have opposite effects in the body
• Hemp based products contain only about 1% THC
• Cannabidiol (CBD) has antagonistic effects to THC (a sedative compound).  Looking at the ratio of THC:CBD ratio – this determines phsychoactivity.
• Neither THC or CBD exist in the native plants, but rather exist as acids (THCA and CBDA)
• The acid is converted to THC and CBD as the plant is cured
• Cannabinol (CBN) is a breakdown product of THC and is inactive
•  Marijuana has been used in history since 8000 BC for medicinal purposes and also documented psychotropic effects. 
• 1975 Nabilone appears for medication purposes and in 1985 Marinol (synthetic THC) used for cancer patients.  In 1990 cannabinoid receptors were discovered.  California was first state to legalize medical marijuana – subsequent states are passing legislation on medical vs recreational
• If inhaled (most popular method): smoking acts quickly, minimizes the dose required and is non-invasive.  Inhaled drugs go directly into the lung with minimal side effects and avoids hepatic first pass (liver will detoxify the body of foods that are eaten – and will take from what is consumed any toxins) metabolism.  It is systematically absorbed 
• Considered a Schedule 1 drug that is highest prescribing level.   Dronabinol and Nabilone are two FDA approved drugs in use today
• Pharmacology has increased THC levels since early 60’s. 
• THC interacts with CB1 (mostly CNS affected) and CB2 (pheriphery)  receptors that impact the basal ganglia, hippocampus, cerebellum, cerebral cortex, spleen, macrophages, tonsils, bone marrow, and peripheral blood leukocytes.
• Effects of the cannabinoid are complicated and may be dependent on THC:CBD ratio.  May have mood elevation up to 2+ hour with as little as 2.5 mg of THC, generalized CNS depression, drowsiness, sleep.    Could also cause dysphoria, severe anxiety , panic, paranoia.  Can have cognitive impairment, decrease reaction time, impair learning, impair memory.  Impairment can be on as low as 5-10mg THC.  Decreased ability to drive 20mg THC
• Has similar analgesic effects similar to codeine and used for antiemetic at lower doses with a consequential appetite stimulant.  Not concerned addictive but tolerance and dependence are documented at 180mg THC x11-21 days.  Can cause tachycardia (<160 bpm) and peripheral circulation (redness and postural hypotension/fainting), chronic bronchitis/emphysema (similar to tobacco smoking) – smaller doses stimulate coughing and larger dose suppress coughing, could lead to airway obstruction.  Can decrease intraocular pressure and improve lung and spleen macrophage activity.  Components increase dopamine release in the brain.
• If dosed via pulmonary – 50% is absorbed – reaches brain within minutes.  Orally – 15% is absorbed – delayed onset 30-120 minutes but longer duration than in
• Accumulates in fatty tissues – half life is 7 days in single dose with complete elimination in 30 days.  Repeated dosages leads to higher concentrations.  The liver metabolizes.  Excreted in urine and gut but an be reabsorbed from there
• Dronabinol = synthetic TCH and Nabilone = THC analog.  Used for HIV, antiemetic (chemotherapy) and appetite stimulant
• CBC can be used as an anti-inflammatory, antimicrobial, mild analgesics.  THCV can be used as an antiepileptic, appetite suppressant, and preserves insulin producing pancreatic cells.  THCA can be used as an antiproliferative, antispasmodic, and antiemetic. 
• Drugs that can be used: Dronabinol (Marinol) – AIDS associated anorexia, chemo patients; Nabilone (cesarnet) chemotherapy.  Rimonabant – treatment of obesity, affects glucose and lipid metabolism.  Synthetics are considered more superior and easier to control.  Synthetic HU-210= 100-800xTHC and maybe used in Alzheimer’s disease by using anti-inflamatory
• Potential medical uses: cachexia (muscle wasting syndrome), anorexia, obesity, chronic pain, epilepsy (Epidiolex), auto immune disorders, Alzheimers, Parkinsons disease (protects dopamine), smoking cessation, anxiety, phychosis, movement disorders, neuropathic pain in MS (Sativex), GI disorders (inflammatory disorders), glaucoma, cancer treatment  (many are not approved in US or are in research phase)