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It is also a mechanism for relieving and managing stress infantile spasms 6 months old cheap azathioprine 50mg amex, which builds when children are hospitalized and face diffcult procedures and do not have their usual play outlets muscle relaxant walgreens buy generic azathioprine on line. Indications and Contraindications Play therapy may not be a treatment of choice for adolescents per se muscle relaxants for tmj generic azathioprine 50mg, as they may be more comfort able with a more traditional talk therapy approach muscle relaxant eperisone cheap 50 mg azathioprine overnight delivery. However, an accepting attitude and openness to participate in play therapy can be benefcial to children of all ages. Although the toys might not be present, being open to playing games and being very accepting of the adolescent are criti cal to establishing rapport and creating an atmosphere where adolescents can grow and establish a strong sense of self as they cope with a chronic illness. In addition, engaging in play therapy for the purposes of verbalizing concerns may be con traindicated for children with signifcant language and/or cognitive delays. While the therapist may not be able to verbally follow the messages in the play of young children with developmental delays, play therapy is a powerful modality for all children, as it provides the opportunity to work through issues nonverbally. In these cases, stories and music or other creative activities may be advisable ways to help children process their feelings. Logistics Playroom Setup, Toys, and Materials A variety of materials can be used during the play therapy session. Actual medical equipment, such as syringes or bandages, can be used, as well as pretend play toys. Other toys include doctor’s kits with toy stethoscopes, surgical tools, masks, and shots. When using toys, children can feel mastery, change outcomes, express emotions, and have some sense of control related to painful medical procedures and equipment. Children also may view the television show “Doc McStuffns,” which shows a girl, who is a toy doctor, fx the medical needs of toys. Talking about this television show and allowing children to discuss their own show about doctors is a good way to prompt children to feel comfortable about telling their own stories. Clark (2007) also has noted benefts when children bring their own play materials to play sessions, facilitating their ability to infuse meaning into their play as they learn to cope with experiences and feelings related to their chronic illness. When using toys and play materials, the children are actively coping with their emotional experiences. The therapist can understand and address children’s misconceptions and negative coping strategies that hinder their ability to cope with an illness or related medical procedures. If children have diffculty beginning to play with toys, one might comment, as Axline (1974) recommended, “You don’t know quite what you would like to do” (p. She also recommended providing the child with permission not to play, as many may not expect to be able to do this in a therapy session. Treatment Frequency and Duration the timing and duration of the play therapy sessions can vary based on child interest and other setting factors related to being in a hospital. The pediatric therapist is often in a consulting role in a hospital setting, where play therapy can be interrupted for a number of medical and other reasons. Therapists should educate children that sessions can be short in duration or vary in length. The therapist should be honest with the child if a shortened session cannot be continued at a later time. Training caregivers in the use of play is a method for ensuring children have multiple opportunities to express their emotions through medical play. Sessions also may be longer than the traditional therapy hour that is adhered to in other community or private practice settings. The duration of sessions should be determined by presenting problems and child and family needs. The duration of treatment may be longer when children have exposure to trauma related to their illness. Pthomegroup Play Therapy With Children Experiencing Medical Illness and Trauma 443 As mentioned earlier, children are living longer and undergoing more medical procedures as technology advances (van der Lee et al. Therefore, pediatric play therapists need to consider a long-term developmental perspective as they assist children and families in coping with an illness. A fexible therapy approach is recommended, in which a therapist has multiple periods of treatment as required by exacerbation of symptoms or based on developmental needs. Pretreatment Intake and/or Assessment and Treatment Planning the play therapist should assess whether a child would beneft from play therapy after conducting a thorough pretreatment clinical intake and understanding the child’s family structure, history, coping skills, and previous experiences, along with obtaining a description of the child’s person ality and typical manner of coping with stressors (Rae & Sullivan, 2005). Observations during play therapy sessions provide key information for assessing children’s functioning in terms of their language, cognitive, emotional, and motor functioning. Clark (2007) recommended therapists be creative in designing assessment tools and consider using multiple methods for measuring change in children’s behaviors. In our work we have used surveys to assess change in child anxiety and emotional functioning. We also use structured assessments, informal child and caregiver report, and observations. Other functional areas to assess include emotional expression, emotion regulation, and abilities to relax and control pain. We believe there are several key areas to assess when conducting play therapy with children. Social Adjustment Play with family members and siblings Peer relationships Social skills Play with peers in school and other contexts; is the child more peer oriented and less isolated We recommend assessment of multiple behaviors and emotions to determine the effect of play therapy within this specifc population. It is important to use multi ple informants, such as the child, medical team, caregivers, and teachers, to determine whether positive change in child functioning is occurring. While it is suggested that the play therapist use a variety of assessment tools, there may not be an opportunity to purchase standardized measures in many clinical settings. Even when standard ized assessment tools are not available, repeated assessment of change in the child’s emotional, behavioral, and social functioning over time is possible. This change can be assessed by brief care giver interviews, teacher interviews, and observations of the child’s play by the aforementioned informants as well as observation by the therapist. Children may also provide subjective ratings of improvement in their skills, such as abilities to manage pain and adhere to treatment regimens. These ratings can be on formal measures or visual analog scales where the children assess change in their own functioning at different points during treatment. In experimental studies of play ther apy, it is recommended that those observing for possible change in play behavior be blind to the purpose of the observations. For example, if play sessions occur at different phases in the child’s development, it may be important to examine the relationship between changes in cognitive functioning and change in children’s emotional, behavioral, and social functioning each time the child returns for additional treatment. Also, if the child has intensive treatments that may affect cognitive development or functioning, it will be important for the therapist to assess the child’s cognitive functioning and development. Child cognitive development and emotional and behavioral functioning change over time, and the therapist may be asked to interact with children at different points in their development, as disease progresses, or as symptoms wax or wane. In this chapter, we elected to focus on discussion of strategies for humanistic and nondirec tive play therapy (Axline, 1974) because research has shown that these approaches are effective for children. However, within nondirective play therapy sessions, therapists can also address child problem-solving skills and teach coping strategies. For instance, the play therapist can teach children ways to cope with medical procedures and ask questions of doctors and other medical professionals, which could improve their ability to cope with pain or behavioral adjust ment in the medical setting. If problem solving were an intervention within play therapy sessions, the therapist could use interviews and self-report measures to assess change in child problem solv ing and use of coping strategies when the child is dealing with the medical team, adherence to her medical regimen, or coping with pain. Because change can have a cascading effect, the thera pist could also see positive change in emotional functioning or relationships with others, such as caregivers and siblings, when children are better able to cope with medical procedures and issues related to their medical condition. Treatment Stages and Strategies the frst year after diagnosis of a medical illness may be an especially diffcult time in the life of the child and family as they adjust to the child’s disease (Barlow & Ellard, 2005). This is a time when the therapist might expect to be more intensively involved, offering regular sessions. Grief Pthomegroup Play Therapy With Children Experiencing Medical Illness and Trauma 445 reactions are common, and many children must adjust to a disruption in their routine activities. The therapist should be present in the sessions, listening to children and the stories in their play and assisting them in processing feelings as well as in gaining a greater knowledge about how to manage their illness. It also is important for therapists to be available to meet with children when they face various medical procedures or experience diffculty coping with an intensifed course of disease-related symptoms. Specially, we present information in six key areas: (1) caregiver training in play therapy; (2) the use of play therapy in preparing children for hospitalization and medical procedures; (3) play therapy as a tool in understanding adherence issues; (4) play therapy as a tool for allowing children to work through and cope with traumatizing and upsetting experiences in an environment where they can control the unfolding of events; (5) play therapy as a technique for assisting children in coping with anticipatory grief; and (6) the use of imagery and fantasy play during sessions. Caregiver Training in Play Therapy: Filial Therapy Therapists may also serve in a training role, utilizing flial therapy to coach caregivers to help their children work through feelings related to coping with illnesses. During flial therapy, caregivers and the child have an opportunity to reconnect and reestablish their relationship. The care giver and child typically participate in play sessions that are supervised by the therapist.

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Block has more than a dozen Use it spasms colon symptoms purchase azathioprine 50 mg on line, not the pronoun she muscle relaxant drugs methocarbamol azathioprine 50mg fast delivery, in definitions muscle spasms 37 weeks pregnant discount 50mg azathioprine, but a political alliance references to spasms hiatal hernia buy azathioprine cheap boats and ships. The derlines for bylines atop a story, name is derived from the nick and for separate subhead lines if name for Mary I of England. Boy Scouts the full name of the national organization is Boy boo-boo Scouts of America. Exploring is a separate pro gram open to boys and girls from borscht high school age through 20. Brand names normally should be used only if they are essential boycott, embargo A boy to a story. It usually pro pocket may be preferable to the hibits goods from entering or less specific cigarette. When a company sponsors an 33 event such as a tennis tourna Britain Acceptable in all ref ment, use the company’s name erences for Great Britain, which for the event in first reference and consists of England, Scotland and the generic term in subsequent Wales. British Airways the suc Also use a separate paragraph cessor to British European Air to provide the name of a sponsor ways and British Overseas Air when the brand name is not part ways Corp. Bricklayers, Masons and British Columbia the Plasterers’ International Canadian province bounded on Union of America the short the west by the Pacific Ocean. British thermal unit the amount of heat required to in brigadier See military crease the temperature of a titles. A form with a community name in date of epidemic typhus fever in which lines on stories from these is the disease recurs years after the lands. Bronze Age the age charac Buddhists believe that correct terized by the development of thinking and self-denial will en bronze tools and weapons, from able the soul to reach nirvana, a 3500 to 1000 B. Regarded as state of release into ultimate en coming between the Stone Age lightenment and peace. It bullfighting is dominant among Buddhists in Cambodia, Laos, Myanmar, Thai bullpen One word, for the land and Sri Lanka. The sect is found mostly in Japan, bureau Capitalize when part Korea and eastern China. The doctrines are burglary vary, but in general a again similar to Mahayana and burglary involves entering a like Mantrayana there is a loose building (not necessarily by structure of leaders and disciples. Larceny is the legal term for Bufferin A trademark for the wrongful taking of property. Theft describes a larceny that Capitalize the proper names of did not involve threat, violence or buildings, including the word plundering. The term most often is associated with spe cial elections to the British House of Commons. Nicknames should not be used unless they specifically are re quested by the writer. Licenses issued since has not made his Cabinet selec then use four letters and four fig tions. The capital letter distinguishes Shortwave stations, which op the word from the common noun erate with greater power than citi meaning cupboard, which is low zens band stations and on differ ercase. Use Camp Fire Boys and Girls hyphens to separate the type of the full name of the national or station from the base call letters: ganization formerly known as 38 Camp Fire, Inc. Both girls and boys are includ canal Capitalize as an inte ed in all levels of the organization. Children in referring to the Panama Canal sixth through eighth grades are area during the time it was con Discovery members. For all other datelines, use the city name and cancel, canceled, cancel the name of the province or terri ing, cancellation tory spelled out. The 10 provinces of Canada cannon, canon A cannon is are Alberta, British Columbia, a weapon. The three territories are the cant the distinctive stock Yukon, the Northwest Territories, words and phrases used by a par and Nunavut (created April 1, ticular sect or class. The provinces have substan tial autonomy from the federal cantor See Jewish congrega government. The territories are adminis tered by the federal government, Canuck this reference to a although residents of the territo Canadian is sometimes consid ries do elect their own legislators ered a derogatory term. Some common the full name on first reference in nouns receive proper noun status wire copy. On second reference in when they are used as the name wire copy, either repeat the full of a particular entity: General name or use the cape in lower Electric, Gulf Oil. Use a Among entries that provide ad capital letter only if you can justi ditional guidelines are: fy it by one of the principles listed animals historical periods here. Entries datelines months that are capitalized without fur days of the week monuments ther comment should be capital directions and nationalities and ized in all uses. Use lowercase bodies plants if the dictionary lists it as an ac foreign legislative police department ceptable form for the sense in bodies religious which the word is being used. Lowercase formal titles effective equivalent: the Combat when used alone or in construc Zone (a section of downtown tions that set them off from a Boston), the Main Line (a group of name by commas. Philadelphia suburbs), the South Use lowercase at all times for Side (of Chicago), the Badlands terms that are job descriptions (of North Dakota), the Street (the rather than formal titles. Capitol tice of lowercasing the common and the Capitol when referring to noun elements of a name when the building in Washington: the they stand alone. Christian, Christianity, English, Thomas Jefferson designed the French, Marxism, Shakespearean. Lowercase words that are de rived from a proper noun but no captain See military titles longer depend on it for their for military and police usage. A carat is equal to 200 In poetry, capital letters are milligrams or about 3 grains. See composition titles; maga cardinal See Roman zine names; and newspaper Catholic Church. Among caretaker churches in this last category are the Polish National Catholic Caribbean See Western Church and the Lithuanian Na Hemisphere. Lowercase catholic where used carmaker, carmakers in its generic sense of general or universal, meanings derived from car pool a similar word in Greek. To censor is to prohibit or re celebrant, celebrator Re strict the use of something. Centers for Disease Con Use celebrator for someone trol and Prevention the cen having a good time: the celebra ters, located in Atlanta, are the tors kept the party going until 3 U. The normal form for first refer Celsius Use this term rather ence is the national Centers for than centigrade for the tempera Disease Control and Prevention. The Celsius scale is named for Anders Celsius, a Swedish as centi A prefix denoting one tronomer who designed it. Move a deci zero represents the freezing point mal point two places to the left in converting to the basic unit: of water, and 100 degrees is the 155. To convert to Fahrenheit, mul tiply a Celsius temperature by 9, centigrade See Celsius. The proper term is concrete (not ce Central Conference of ment) pavement, blocks, drive American Rabbis See Jewish ways, etc. On Henry Ford, committee Chair first reference: Director George woman Margaret Chase Smith. Use the chancellor the translation to $ sign and decimal system for English for the first minister in larger amounts: $1. Charles Chagas, a Brazilian Lowercase when standing physician who identified the alone. The major pieces are shown by a Charles Town is the name of a capital letter: K for king, Q for small city in West Virginia. Kingside is the Chemical Mace A trade side of the board (right half from mark, usually shortened to Mace, white’s point of view, left half for a brand of tear gas that is from black’s), on which each packaged in an aerosol canister player’s king starts. For instance, if white’s knight, rook, kingside, queenside, bishop captures the black pawn white, black. The ranks take num pawn was on and the square bers, 1 to 8, beginning on white’s where it made the capture. If black’s 45 pawn on an f file captured the merger of Chevron and Texa white’s, it would be fxg5. If there are black knights on c6 and e6, and the chief Capitalize as a formal one on e6 moves to d4, the move title before a name: She spoke to is given as Ned4. He the form, taken from a 1993 spoke to Chief Michael Codd of the championship match: New York police.

The annual the most effective way to muscle relaxant gaba generic azathioprine 50 mg with amex improve vaccination rates impact of seasonal infuenza in the United States: measuring dis ease burden and costs zopiclone muscle relaxant buy azathioprine 50 mg mastercard. In a survey during the 2010–2011 infuenza enza A(H3N2) variant virus in the United States spasms nose buy generic azathioprine on line, 2011–2012 spasms in hand buy azathioprine 50 mg cheap. Effcacy and safety of the employer required vaccination, compared with only 58% oral neuraminidase inhibitor oseltamivir in treating acute infuenza: among those whose employers did not require vaccination a randomized controlled trial. Early oseltamivir treat variety of national organizations, including the Infectious ment of infuenza in children 1–3 years of age: a randomized con Diseases Society of America, the American College of trolled trial. Antiviral therapy and out comes of infuenza requiring hospitalization in Ontario, Canada. Accessed August 5, began requiring hospitals to report their rate of infuenza 2013. Infections with oseltami Infuenza is a common respiratory illness that is associ vir-resistant infuenza A(H1N1) virus in the United States. Characteristics of pa tients with oseltamivir-resistant pandemic (H1N1) 2009, United tions, and they need to use available surveillance to rec States. A cluster of patients infected with Physicians also need to follow current recommendations on I221V infuenza B virus variants with reduced oseltamivir suscepti bility—North Carolina and South Carolina, 2010-2011. Seasonal infu dated infuenza vaccine effectiveness estimates for the 2012-13 fu enza (fu): interim guidance for infuenza outbreak management in season. Infuenza illness and hospitaliza cination coverage among health-care personnel—United States, tions averted by infuenza vaccination in the United States, 2005 2010-11 infuenza season. For example, our institution—New Hanover the development of national core measures for the manage Regional Medical Center in Wilmington, North Carolina— ment of pneumonia. Although it does not signify causation, has the following goals: that antibiotics be administered to implementation of these standards strongly correlates with patients with pneumonia within 6 hours of their arrival at a decrease in the incidence of pneumonia and with decreas the hospital; that blood cultures be obtained prior to admin ing death rates from pneumonia. Similar standards have been established by neumonia, together with infuenza, has caused a great the Centers for Medicare & Medicaid Services and the Joint Pburden of suffering throughout history. It ranked as the Commission, both of which accredit health care organiza leading cause of death in the early 1900s and was still among tions and programs. Indeed, pneumonia consensus guidelines on the management of health care– remains the most common cause of infection-related mor associated pneumonia, which includes hospital-acquired tality in the United States. The age-adjusted death rate treatment of patients after they acquire pneumonia and also in the United States in 2010 for pneumonia and infuenza recommend various measures to decrease the incidence of combined was 15. Frequently recognized standards from the health the 1-year mortality rate for Medicare patients who have care–associated pneumonia guidelines include elevating been hospitalized with community-acquired pneumonia is the head of the bed for patients with pneumonia and giving as high as 40% [6]. In the United States in 2010, pneumo mechanically ventilated patients daily “sedation vacations” nia was listed as the frst diagnosis on hospital discharge in order to prevent pneumonia. In 2006 the rate of discharge for encourage vaccination against infuenza and pneumococcal patients with pneumonia as the frst diagnosis was 189. Clinicians may 2005, with more than $34 billion in direct costs and $6 billion reasonably decide to deviate from these guidelines, and in indirect costs [5]. The economic burden from community it is not expected that every patient will receive the same acquired pneumonia alone is estimated to exceed $17 bil exact care. Nevertheless, hospital guidelines and core mea lion annually, including costs for approximately 4. Because of these changes, it is diff ity, in-hospital mortality, and hospital length of stay [11]. As cult to draw conclusions when comparing data from 1998 health care systems in the United States implement these and prior years with data from subsequent years [11, 12]. Beginning with death rates compiled under the new stan dard in 1999 and comparing those more recent mortality sta Patient-Oriented Outcomes tistics, pneumonia death rates have decreased signifcantly. Over the past decade, most measures of pneumonia mor Between 1999 and 2010, age-adjusted death rates for pneu bidity and mortality have shown improvement, coinciding monia and infuenza decreased 35%, from 23. Between lishment of core measures for the treatment and prevention 1999 and 2006, the age-adjusted death rate for white men of pneumonia. This is unfortunate, given that elderly indi those older than 65 years, it decreased from 206. Fortunately, infuenza vaccination rates for some When comparing annual death rates for pneumonia and high-risk groups have improved; for example, the percent infuenza for various years, it is important to keep in mind age of adults with asthma who received an infuenza vacci that the population standard for calculating age-adjusted nation increased from 40. The new standard places more Although the percentage of elderly patients receiving weight on death rates at older ages and less weight on death infuenza vaccine has remained consistent, the rate of pneu rates at younger ages. Because the incidence of lung diseases mococcal vaccination in elderly individuals has increased increases with age, death rates for pneumonia and infuenza dramatically over the past decade or so. According to the National Health Interview Survey, persons Because pneumonia is often a fnal consequence of another age 65 year or older—including persons who were not nurs chronic or acute condition, such as chronic obstructive pul ing home residents—yielded a similar pneumococcal vacci monary disease, pneumonia mortality statistics are particu nation rate of 42. The total number of cases Hanover Regional Medical Center, Wilmington, North Carolina. Although racial and ethnic dispari ties still exist, pneumonia outcomes appear to be improving Acknowledgments for most groups. American Lung Association, Research and Program Services, Epi many eligible patients are still being missed. Accessed cination rates for most diseases that are consistently above July 1, 2013. Infectious Diseases health care settings have been developed and subsequently Society of America/American Thoracic Society consensus guide lines on the management of community-acquired pneumonia in updated. It is extremely Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J important to remember that correlation does not imply cau Respir Crit Care Med. Indeed, there are myriad fac process-of-care and outcomes after implementing a guideline for the management of community-acquired pneumonia: a controlled tors other than the practice guidelines and core measures before-and-after design study. Pneumonia: still the old Past studies of the epidemiology of pneumonia have not man’s friend Number and rate of dis and health care–associated pneumonia; hypothetically, if charges from short-stay hospitals and days of care, with average it were determined that most of the improvement in pneu length of stay and standard error, by selected frst-listed diagnos tic categories: United States, 2010. Accessed former, then advances in technology and critical care medi July 1, 2013. However, future Estimates Based on Data from the 2011 National Health Interview Sur assessments might be able to use billing and coding data to vey. This report bacteria are a known cause of serious bacterial examines the prevalence of pneumococcal vacci infections, including meningitis, blood infections, nation among North Carolina adults and the state’s ear infections, sinus infections, and most cases progress toward achieving these Healthy People of pneumonia (pneumococcal pneumonia) [1]. Pneumococcal Vaccination Rates for Respondents Aged 65 Years or Older, North Carolina Behavioral Risk Factor Surveillance System Survey, 2011 Reported having received the Reported not having ever received Total no. Column totals may not add up to the overall total because some values for demographic characteristics are missing. Estimates based on a small number of respondents have been suppressed because they do not meet statistical reliability standards. Elderly respondents Healthy People 2020 target vaccination rate of with a disability were slightly more likely to report 90% for elderly individuals. Additionally, North Carolina’s pneu was also higher among elderly respondents who monia vaccination rate for nonelderly adults with were white; 74. Rates for other were current smokers had the lowest vaccination racial groups and Hispanic individuals were not rates; only about 1 in 5 people in this group—19. The pneumococcal other risk factors have pneumococcal vaccination vaccination rate for nonelderly adults with chronic rates that fall well below national targets estab table 2. Pneumococcal Vaccination Rates for Respondents Aged 18–64 Years with Selected Chronic Conditions or Risk Factors, North Carolina Behavioral Risk Factor Surveillance System Survey, 2011 Reported having received the Reported not having ever received Total no. Streptococcus pneumoniae: epi about the importance of the pneumococcal vaccine demiology and risk factors, evolution of antimicrobial re sistance, and impact of vaccines. Offce of Statistics, Division of Public Health, North Carolina Disease Prevention and Health Promotion. Obesity complicates existing health problems, at age 12 years than those children who were not overweight creates increased risks for disease and other health at those ages. The adverse outcomes of obesity can occur throughout a 50% probability of becoming obese adults compared to a a person’s lifetime—from childhood to adulthood.

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Many families in India are increasingly allowing sons veto power over the parents’ choice of his future spouse muscle relaxant lotion buy genuine azathioprine on-line, and some families give daughters the same say spasms prozac azathioprine 50mg fast delivery. Marital Arrangements in India: As the number of arranged marriages in India is declining muscle relaxant benzodiazepine buy generic azathioprine canada, elopement is increasing zanaflex muscle relaxant buy discount azathioprine 50 mg on-line. Allendorf’s (2013) study of a rural village in India, describes the elopement process. In many cases the female leaves her family home and goes to the male’s home, where she stays with him and his parents. After a few days, a member of his family will inform her family of her whereabouts and gain consent for the marriage. In other cases, where the couple anticipate some degree of opposition to the union, the couple may run away without the knowledge of either family, often going to a relative of the male. After a few days, the couple comes back to the home of his parents, where at that point consent is sought from both families. Although, in some cases families may sever all ties with their child or encourage him or her to abandon the relationship, typically, they agree to the union as the couple have spent time together overnight. Once consent has been given, the couple lives with his family and are considered married. Arranged marriages are less common in the more urban regions of India than they are outside of the cities. In rural regions, often the family farm is the young person’s only means of employment. As a result, they are often less economically dependent on their families, and may feel freer to make their own choices. Thornton (2005) suggests these changes are also being driven by mass media, international 290 travel, and general Westernization of ideas. Besides India, China, Nepal, and several nations in Southeast Asia have seen a decline in the number of arranged marriages, and an increase in elopement or couples choosing their own partners with their families’ blessings (Allendorf, 2013). Predictors of Marital Harmony: Advice on how to improve one’s marriage is centuries old. Gottman (1999) differs from many marriage counselors in his belief that having a good marriage does not depend on compatibility. At the University of Washington in Seattle, Gottman has measured the physiological responses of thousands of couples as they discuss issues of disagreement. Fidgeting in one’s chair, leaning closer to or further away from the partner while speaking, and increases in respiration and heart rate are all recorded and analyzed along with videotaped recordings of the partners’ exchanges. Gottman believes he can accurately predict whether or not a couple will stay together by analyzing their communication. In marriages destined to fail, partners engage in the “marriage killers”: Contempt, criticism, defensiveness, and stonewalling. Each of these undermines the politeness and respect that healthy marriages require. Stonewalling, or shutting someone out, is the strongest sign that a relationship is destined to fail. Gottman, Carrere, Buehlman, Coan, and Ruckstuhl (2000) researched the perceptions newlyweds had about their partner and marriage. The Oral History Interview used in the study, which looks at eight variables in marriage including: Fondness/affection, we-ness, expansiveness/ expressiveness, negativity, disappointment, and three aspects of conflict resolution (chaos, volatility, glorifying the struggle), was able to predict the stability of the marriage with 87% accuracy at the four to six year-point and 81% accuracy at the seven to nine year-point. Gottman (1999) developed workshops for couples to strengthen their marriages based on the results of the Oral History Interview. Interventions include increasing the positive regard for each other, strengthening their friendship, and improving communication and conflict resolution patterns. Accumulated Positive Deposits: When there is a positive balance of relationship deposits this can help the overall relationship in times of conflict. For instance, some research indicates that a husband’s level of enthusiasm in everyday marital interactions was related to a wife’s affection in the midst of conflict (Driver & Gottman, 2004), showing that being pleasant and making deposits can change the nature of conflict. Also, Gottman and Levenson (1992) found that couples rated as having more pleasant interactions, compared with couples with less pleasant interactions, reported marital problems as less severe, higher marital satisfaction, better physical health, and less risk for divorce. Finally, Janicki, Kamarck, Shiffman, and Gwaltney (2006) showed that the intensity of conflict with a spouse predicted marital satisfaction, unless there was a record of positive partner interactions, in which case the conflict did not matter as much. Again, it seems as though having a positive balance through prior positive deposits helps to keep relationships strong even in the midst of conflict. Intimate Partner Abuse Violence in romantic relationships is a significant concern for women in early adulthood as females aged 18 to 34 generally experience the highest rates of intimate partner violence. The study found that nationwide, 93% of women killed by men were murdered by someone they knew, and guns were the most common weapon used. The national rate of women murdered by men in single victim/single offender incidents dropped 24%, from 1. Intimate partner violence is often divided into situational couple violence, which is the violence that results when heated conflict escalates, and intimate terrorism, in which one partner consistently uses fear and violence to dominate the other (Bosson, et al. Men and women equally use and experience situational couple violence, while men are more likely to use intimate terrorism than are women. Consistent with this, a national survey described below, found that female victims of intimate partner violence experience different patterns of violence, such as rape, severe physical violence, and stalking than male victims, who most often experienced more slapping, shoving, and pushing. Based on the results, women are disproportionately affected by intimate partner violence, sexual violence, and stalking. Results included: Source • Nearly 1 in 3 women and 1 in 6 men experienced some form of contact sexual violence during their lifetime. Children are less likely to be living with both parents, and women in the United States have fewer children than they did previously. The average fertility rate of women in the United States was about seven children in the early 1900s and has remained relatively stable at 2. Not only are parents having fewer children, the context of parenthood has also changed. Parenting outside of marriage has increased dramatically among most socioeconomic, racial, and ethnic groups, although college-educated women are substantially more likely to be married at the birth of a child than are mothers with less education (Dye, 2010). The birth rate for women in their early 20s has declined in recent years, while the birth rate for women in their late 30s has risen. For Canadian women, birth rates are even higher for women in their late 30s than in their early 20s. In 2011, 52% of births were to women ages 30 and older, and the average first-time Canadian mother was 28. Source Despite the fact that young people are more often delaying childbearing, most 18 to 29-year-olds want to have children and say that being a good parent is one of the most important things in life (Wang & Taylor, 2011). Influences on Parenting: Parenting is a complex process in which parents and children influence on another. Proposed influences on parenting include: Parent characteristics, child characteristics, and contextual can sociocultural characteristics. Parent Characteristics: Parents bring unique traits and qualities to the parenting relationship that affect their decisions as parents. These characteristics include the age of the parent, gender, beliefs, personality, developmental history, knowledge about parenting and child development, and mental and physical health. Mothers and fathers who are more agreeable, conscientious, and outgoing are warmer and provide more structure to their children. Parents who are more agreeable, less anxious, and less negative also support their children’s autonomy more than parents who are anxious and less agreeable (Prinzie, Stams, Dekovic, Reijntes, & Belsky, 2009). Parents who have these personality traits appear to be better able to respond to their children positively and provide a more consistent, structured environment for their children. Fathers whose own parents provided monitoring, consistent and age-appropriate discipline, and warmth were more likely to provide this constructive parenting to their own children (Kerr, Capaldi, Pears, & Owen, 2009). Patterns of negative parenting and ineffective discipline also appear from one generation to the next. However, parents who are dissatisfied with their own parents’ approach may be more likely to change Source their parenting methods with their own children. Child characteristics, such as gender, birth order, temperament, and health status, affect parenting behaviors and roles. Over time, parents of more difficult children may become more punitive and less patient with their children (Clark, Kochanska, & Ready, 2000; Eisenberg et al. Parents who have a fussy, difficult child are less satisfied with their marriages and have greater challenges in balancing work and family roles (Hyde, Else-Quest, & Goldsmith, 2004). Thus, child temperament, as previously discussed in chapter 3, is one of the child characteristics that influences how parents behave with their children.

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Tracking lets the child know the therapist is completely involved in the play and is watching everything the child is doing and hearing everything the child is saying muscle relaxant tea buy azathioprine toronto. The child does not have to muscle relaxant drugs specifically relieve muscle azathioprine 50 mg without a prescription interrupt the play to quad spasms after squats buy azathioprine 50mg otc check to knee spasms at night order 50mg azathioprine with mastercard see if the therapist is still paying attention. It gives the child the message the therapist understands the pur pose and direction of the play. Refection of Content While tracking assures the child that the therapist is present and sees and hears the child, refecting verbalized content communicates the therapist’s acceptance and understand ing. The play therapist summarizes or paraphrases and refects back the child’s verbal interactions during the play session. Refection of Feelings the ability to recognize and properly refect feelings is essential in helping children to be able to accept the full range of emotions that may arise during play therapy. As children’s feelings are verbally acknowledged and accepted, they can be more open in expressing them. Refecting a child’s feelings validates the child and facilitates self-trust (Landreth, 2012). Although refecting feelings may appear simple, it can be quite diffcult to imple ment. The therapist may become distracted by the child’s play and forget to look at the child’s face and read the frustration, anger, happiness, or pride. The therapist may fnd the child’s expression of feelings to be painful or excessive and attempt to dissuade the child from feeling that way. This gives the child the message that the child’s feel ings are unacceptable or possibly wrong. The therapeutic relationship is strengthened when the therapist communicates acceptance and understanding. In any group situation, it is important for children to understand the boundaries and know the therapist will keep them safe, not only from each other, but from themselves. Guerney (2001) describes therapeutic limit-setting as “the pairing of limit-setting state ments with empathic statements about the child’s desire to break the limits” (p. Landreth and Sweeney (1997) summarized the following in regard to limit-setting in general and how limits defne the boundaries of the therapeutic relationship: Limits provide security and safety for the child, both physically and emotionally. When a child becomes frustrated, too excited, or wants something that has been placed off-limits, the emotion can be overwhelming. Part of setting appropriate limits for a child is to help the child understand the impact of emotions on decision making. Ther apeutic limit-setting takes this into consideration by providing clear direction about the unacceptable behavior and by giving the child an opportunity to make a choice. It provides opportunities for reality testing and for expressing feelings and needs in more acceptable ways (Sweeney & Homeyer, 1999). In many ways, it resembles simultaneous individual sessions as group members are free to choose to participate in solitary, parallel, or shared play. Therapeutic responses are not intrusive and generally include the child’s name so that the group members know to whom the response is directed. The therapist keeps responses balanced between group members and avoids placing the focus on any particular child. The opportunity for children to connect with each other in reciprocal ways leads to an increased capacity to redirect behavior into a more self-enhancing and interpersonally appro priate manner. Through playing with peers, children develop skills for seeing something from another person’s point of view, cooperating, helping, and sharing, as well as for solving problems (Sawyers & Rogers, 1988). They develop leading and following behaviors, both of which are needed to get along well as adults. Such experiences help children think about their social world and gain an understanding of themselves. Pthomegroup Child-Centered Play Therapy 109 Limits and limit-setting are unique in the therapeutic group as group members experience limits set not only by the therapist but also by the other group members (Sweeney & Homeyer, 1999). The group therapist maintains minimal, yet appropriate, limits without taking control of the session. As long as physical and emotional safety concerns are addressed, the group therapist allows children to work conficts out for themselves. The addition of multicultural issues to group counseling can complicate the situation. If the group itself is diverse, the therapist needs to be especially sensitive to the reactions, needs, and differences each child brings to the group (Glover, 1999). Not only will the therapist need to be accepting of differences as strengths, but some education may be required for other group members. Opportunities to set limits on inappropriate behavior between children because of mis understanding due to cultural differences can only be taken advantage of if the therapist is aware of the impact. If the opportunity exists for a group to be formed that consists of members from a single culture which is different than the therapist’s, the therapist has the chance to learn from the group members. A parent or caregiver of some type who is intimately involved with the child accompanies the child. It is highly likely the child would not have chosen to come to therapy had an adult not brought the child. Therefore, the therapist must interact on some level with the adults in the lives of their child clients. It is also helpful for caregivers to know the developmental needs of children and how therapy can be a positive intervention when development is not progressing in a typical fashion. The caregiver’s role in therapy includes being supportive of the therapeutic process by bring ing the child to all scheduled appointments on time and also by maintaining open and clear communication with the therapist. Trust in therapy will develop if the caregiver is made aware of and understands the therapeutic process and is kept informed of progress or lack of progress by the therapist. In turn, the caregiver is generally the best source for information regarding any changes outside the therapy sessions. It is diffcult to measure true progress in this “artifcial” play therapy situation. The real test is the child’s behaviors in the real-world environments of home and school. Sometimes, a behavior that has become inconvenient was inadvertently supported by the caregiver. Consultation provides an opportunity for the therapist to present new strategies for the caregiver to use with the child at home to remediate the behavior. Consultation time also provides an opportunity for the therapist to convey the importance of play to caregivers and other adults who care for children as an essential aspect of the therapeutic process. For young children 18 months to 10 years of age, play therapy is the developmentally appropriate modality; however, using play to facilitate positive change in children can be contro versial for the caregivers. They may not necessarily see the value of play or its role in achieving healthy behaviors and emotions. The play therapist can help caregivers understand how young children do not typically have the cognitive capacity to talk about things that are interfering with their lives. Providing this play experience for a child in the presence of a trained, caring, and accept ing play therapist allows children to express things they are not capable of expressing in words: Play is the child’s symbolic language of self-expression and can reveal (a) what the child has experienced; (b) reaction to what was experienced; (c) feelings about what was expe rienced; (d) what the child wishes, wants, or needs; and (e) the child’s perception of self. Play provides the opportunity for children to practice new cognitive, social-emotional, and physical skills. It offers numerous opportunities for children to act on objects and experience events. Play enables children to use their real experiences to organize concepts of how the world operates. Play reduces the tension that often comes with having to achieve or need to learn. Children express and work out emotional aspects of everyday experiences as well as frightening events, especially through dramatic play. Bernard and Louise Guerney as an alternative method for treating young children with behavioral and emotional problems that would assist caregivers in creating a stronger, more ther apeutic relationship with their children (Guerney, 1964). By utilizing the emotional bond that naturally exists between the parent and child, professionalscan further empower parents by teach ing them basic psychotherapeutic techniques (Authier, Gustafson, Guerney, & Kasdorf, 1975). Combining a support group format with didactic instruction provides a dynamic process that sets Filial Therapy training apart from other parent training programs (Ginsberg, 1976). Through the Filial Therapy training sessions, caregivers learn to become constructive forces for change in their children’s behaviors and attitudes by using basic child-centered play therapy principles in special weekly play sessions with their children (Guerney, 1982).

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Early talks on the foundation of the SGA. The meeting was held in Professor Amstutz's office at the University of Heidelberg on 19./20. June 1965. Sitting (from left) A. Maucher, Lombard, P. Routhier, P. Ramdohr, G.L. Krol; standing: A. Bernard and C. Amstutz.